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MINOE SURGERY. 



ON 



BANDAGING, 



AXD OTHER 



OPEEATIONS 



MINOR SURGERY. 



F. W. SARGENT, M.D., 

MEJIBER OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; ONE OF THE SURGEONS 
TO WILLS' HOSPITAL, ETC. ETC. 



NEW EDITION, REVISED AND ENLARGED. 



ONE HUNDRED AND EIGHTY- ONE ILLUSTRATIONS. 




PHILADELPHIA: 
BLANCHARD AND LEA. 

1856. 



"9v 



Entered, according to Act of Congress, in the year 1855, by 

BLANCHARD & LEA, 

in the Clerk's Office of the District Court of the United States in and for the 
Eastern District of Pennsylvania. 

Printed "by T. K & P. G. Collins. 



TO 

GEORGE W. NORRIS, M. D., 

SURGEON TO THE PENNSYLVANIA HOSPITAL, 

AS A TRIBUTE OF RESPECT 

FOR HIS PROFESSIONAL AND PERSONAL CHARACTER, 

AND IN ACKNOWLEDGEMENT 

OF HIS INSTRUCTIONS AND REPEATED KINDNESS, 

\\% ffllttttU 
IS INSCRIBED 

BY THE AUTHOE. 

1* (v) 



PREFACE TO THE NEW EDITION. 



The very kind manner in which the first edition of this 
little book was received, has stimulated the Author to renewed 
diligence in adding to it whatever seemed to him calculated 
to augment its usefulness and its comprehensiveness. He 
hopes that his efforts will be found successful. 

By an increase in the size of the page, it will be seen that 
the considerable additions to this edition have been introduced 
without causing any enlargement of the volume. 



(Yii) 






PREFACE. 



The object which the Author has had in view in the pre- 
paration of the following pages, has been, to present to the 
younger surgeon, and to the student, information relative to 
the art of bandaging, and to some other points of importance 
in the practice of surgery. These are subjects which are but 
slightly alluded to in systematic courses of lectures, or in most 
of the published treatises on the science ; yet the necessity of 
a familiar acquaintance with them will be readily acknowledged 
by every surgeon of experience. 

In the collection of the materials for this volume, the Au- 
thor has availed himself very freely of the knowledge of 
others, as exhibited in books, and of his own opportunities in 
hospitals and in private, of gaining practical acquaintance 
with the subjects of which he has treated. He trusts that he 
has not failed in his intention, always to give due credit to 
all from whom he has taken information. Originality can 
scarcely be expected, in a work of this kind, excepting, per- 
haps, in its composition. 

The book is divided into five parts. Of these, the first em- 
braces a description of the implements, if such a term be ad- 
missible, with which the ordinary duties of the surgeon are 
accomplished. 

The second treats of the composition and preparation of 
Bandages, of their application to the different regions of the 

(«) 



X PREFACE. 

body, and of the purposes which they are thus made to sub- 
serve. 

The third is devoted to the consideration of the apparatus 
of various kinds, used in the treatment of Fractures. In the 
arrangement of this portion of the volume, the Author has 
thought it expedient to give pretty full details, showing the 
indications of treatment in each particular case of Fracture, 
and thereby rendering more manifest the adaptation of each 
bandage, splint, or other dressing, to the fulfilment of these 
requirements. 

The fourth division describes the mechanical means em- 
ployed in the treatment of dislocations, with the mode of ap- 
plying them. 

In the fifth part are detailed at length the methods of per- 
forming such operations as seem strictly to be included in the 
term "Minor Surgery;" these are the operations for bleed- 
ing, general and local ; the modes of effecting counter-irrita- 
tion ; — the methods of arresting haemorrhage ; the closure 
of wounds ; the introduction of the catheter, and the adminis- 
tration of injections. A few remarks on the mode of relieving 
pain during operations, and a short appendix of useful for- 
mulae, close the volume. 

Philadelphia, May, 1848. 



TABLE OF CONTENTS. 



PREFACES Page vii 

PART I. 
CHAPTER I. 

ON THE INSTRUMENTS USED IN DRESSING 25 

CHAPTER II. 

ON SURGICAL DRESSINGS. 

Lint — Charpie — Cotton — Tow — The Compress — Retractors — The 
Malta Cross — Sponge-Tent — Setons — Adhesive Plasters — Collodion 
— Soap Plaster — Mercurial Plaster — The Poultice — The Water 
Dressing — Spongio-Piline — Lotions — Cerates — Ointments — Lini- 
ments — The Sponge 29 

CHAPTER III. 

GENERAL RULES FOR DRESSING 49 

CHAPTER IV. 

ON THE USE OF WATER.... 52 

SECTION I. 

IRRIGATION 52 

SECTION II. 

THE DOUCHE 54 

SECTION III. 

BATHING. — WATER AND VAPOUR BATHS 57 

(xi) 



I 



Xll CONTENTS. 

SECTION IV. 

ON FUMIGATIONS 

SECTION V. 

ON DISINFECTING AGENTS 

PART II. 

ON BANDAGES AND THEIR APPLICATION 

CHAPTER I. 
SECTION I. 

THE ROLLER, OR SIMPLE BANDAGE. 

Composition and preparation of the Roller — Different modes of appli- 
cation — Circular — Spiral and reversed turns — Crossed — Spica and 
recurrent bandages — Uniting — Dividing — Compressing — Expelling 
— Retaining and Knotted bandages 

SECTION II. 

COMPOUND BANDAGES. 

The T bandage— The Invaginated-- The Split, or Tailed— The Laced 
— The Sheath — And the Suspensory bandages 

SECTION III. 

M. MAYOR'S SYSTEM OF BANDAGES 

CHAPTER II. 

REGIONAL BANDAGING. 

SECTION I. 
BANDAGES FOR THE HEAD AND NECK. 

The Recurrent — The T — The Four-tailed — The Six-tailed bandages 
— The Fronto-occipital Triangle — The Knotted — The Four-tailed 
bandage of the Chin— The T-bandage of the Ear— The double T- 
bandage of the Nose — The sheath of the Nose — Bandages for the 
Eyes — The Invaginated bandage of the Lip — The Sheath of Pibrac 
for the Tongue — The Mask for the Face — The Cervical Cravat — 
The flexor bandage of the Neck — Jorg's flexor of the Neck 77 



CONTEXTS. XU1 

SECTION II. 

BANDAGES FOR THE TRUNK. 

The Dorso-thoracic Triangle — Circular bandage — The bandage of Vel- 
peau — The figure-8 bandage of the shoulders — The Suspensory of 
the breast — The triangular cap for the breast — The Compressor of 
the breast — The Straight-jacket — The Body-bandage — The triangu- 
lar coverings for the Sacrum and Pubis — The triangular bandage 
for the Groin — The Cruro-inguinal triangle — The Spicas of the 
Groin — The Cruro-inguinal cravat — The double T-bandage for the 
Pelvis — Suspensories of the Scrotum — Bandage for the Penis 88 

SECTION III. 

BANDAGES FOR THE UPPER EXTREMITIES. 

The Axillo-clavicular cravats — The figure-8 bandage for the shoulder 
and axilla — Sling for the fore-arm — Triangular bandages for the 
wrist and hand — The Spiral for the arm — The Spica for the arm 
and shoulder — The Spica for the thumb — The Gauntlet — The Demi- 
gauntlet — The cravat bandage for the hand — The perforated ban- 
dage for the hand 99 

SECTION IV. 

BANDAGES FOR THE LOVTER EXTREMITY. 

The Cruro-iliac triangle — The bandage of Scultetus — The eighteen- 
tailed bandage — The invaginated bandages — The figure-8 bandage 
for the knee — Weiss' elastic knee-cap — Common elastic cap for the 
knee — Spiral bandages for the lower extremity — Baynton's bandage 
—The laced stocking— The Gaiter 104 



PART III. 

BANDAGES AND APPARATUS EMPLOYED IN THE TREATMENT OF FRACTURES. 

CHAPTER I. 

GENERAL CONSIDERATIONS. 

Mode of reparation of fracture — Indications of treatment — " The Im- 
movable Apparatus" of Larrey, Seutin, Yelpeau, Laugier, and 
Dieffenbach — The " Hyponarthecia" of Sauter and Mayor — Vehicle 
for transporting injured persons — Mode of exposing the seat of in- 
jury — Fracture-beds — Clinical frame — The apparatus of Jenks, for 
raising the patient from the bed 108 

2 



XIV CONTENTS, 

CHAPTER II. 

BANDAGES AND DRESSINGS FOR FRACTURES OF THE BONES OF THE HEAD 
AND TRUNK. 

SECTION I 
FOR FRACTURES OF THE BONES OF THE SKULL AND FACE. 

Of the bones of the Cranium — Of the Face — The four-tailed bandage 
of the chin, for fractures of the lower jaw — Gibson's and Barton's 
bandages for the same , 121 

SECTION II. 

BANDAGES FOR FRACTURES OF THE BONES OF THE TRUNK. V 

For fractures of the Vertebrae — Of the Ribs and Sternum — Treat- 
ment by compresses and a roller — By lath or pasteboard splints — 
Fractures of the Sternum — Fractures of the bones of the Pelvis — 
Treatment of compound fractures : 124 

CHAPTER III. 

APPARATUS AND DRESSINGS FOR FRACTURES OF THE BONES OF THE SHOULDER. 

SECTION I. 
FOR FRACTURES OF THE CLAVICLE. 

Older methods of treatment — Fox's apparatus — Bandage of Mr. Lons- 
dale — Of Brown — New plan recommended by M. Guillou 128 

SECTION II. 

FOR FRACTURES OF THE SCAPULA. 

Fractures of the body and inferior angle — ■ Of the coracoid process 
— Bandage of M. Velpeau — Of the acromion process and neck — 
Mr. Lonsdale's mode of treatment— Other apparatus— Compound 
fractures » 133 

CHAPTER IY. 
SECTION I. 

FOR FRACTURES OF THE HUMERUS. 

Fracture of the shaft of the bone — Ordinary mode of treatment — 
Mr. Lonsdale's splint — Fractures of the upper extremity of the 



CONTENTS. XV 

bone — At the surgical and anatomical neck — Fracture at the 
condyloid extremity — Sir A. Cooper's method of treatment — Mr. 
Mayo's splint for compound fractures of this portion of the bone — 
Treatment of compound fractures of the humerus generally 138 

SECTION II. 

FOR FRACTURES OF THE BOXES OF THE FORE-ARM. 

Fractures of both bones — Ordinary method of treatment — Mr. Lons- 
dale's plan — The " Ante-brachial Hyponarthecia" of Mayor — 
Fractures of the radius — Of the head of the bone — Of the shaft — 
Of the lower portion of the bone — Dupuytren's splint — Oblique 
fracture of the lower end of the radius — Modes of treatment — 
Fractures of the ulna — Of the coronoid process — Of the olecranon 
process — Sir A. Cooper's plan of treatment — Other methods — Com- 
pound fractures — Partial fractures 148 

SECTION III. 

FOR FRACTURES OF THE BONES OF THE WRIST AND HAND. 

Fracture of the carpal bones — Of the metacarpal bones — Of the pha- 

i — Compound fractures 159 



CHAPTER V. 

APPARATUS AND DRESSINGS FOR FRACTURES OF THE BONES OF THE LOWER 

EXTREMITY. 

SECTION I. 

FOR FRACTURES OF THE OS FEMORIS. 

Treatment in the flexed and straight positions — Treatment of frac- 
tures of the shaft of the bone — By the method of Pott — Of Sir 
Charles Bell — Apparatus used at the Middlesex Hospital — Plan 
of Mr. Amesbury — Splint of Dr. N. R. Smith — Hyponarthecia for 
fractures of the thigh — Treatment by the straight splints of 
Desault — Dr. Physick's modification — Splints of Boyer, Liston, 
Hagedorn, (as modified by Dr. Gibson), and others — Treatment of 
fractures of the upper part of the femur — "Within the capsular liga- 
ment — Exterior to this — Fractures of the lower extremity of the 
bone — Above the condyles — Through these processes — Compound 
fractures of the thigh 163 



XVI CONTENTS. 

SECTION II. 

FOR FRACTURES OF THE PATELLA. 

longitudinal and transverse fractures — Plans of treatment pursued 
by Sir A. Cooper, by Desault, Gerdy, Amesbury, Lonsdale, and 
others — Rupture of the tendon, and ligament of the patella — Com- 
pound fractures of the patella 190 

SECTION III. 

FOR FRACTURES OF THE BONES OF THE LEG. 

Of both bones, treatment by "the Junks" — By the splint of Mr. 
Neville — By the fracture-box — By the splints of Hutchinson — By 
the double inclined plane of Mr. Liston — Other methods — Fracture 
of tibia only — Of the fibula only — "Pott's fracture" — Its treat- 
ment according to Dupuytren — By the fracture-box — Suspension 
method of Sauter and Mayor — Compound fractures — The bran- 
dressing 197 

SECTION IV. 

FOR FRACTURES OF THE BONES OF THE FOOT. 

Of the os calcis — Method of Mr. Lonsdale — Of Druitt — Simple frac- 
tures of the bones of the foot generally — Compound fractures 208 



PART IV. 

ON THE MECHANICAL MEANS EMPLOYED IN THE TREATMENT OF DISLOCATIONS. 

General observations 208 

CHAPTER I. 

DISLOCATIONS OF THE BONES OF THE HEAD AND TRUNK. 

SECTION I. 
OF THE LOWER JAW. 

Reduction — Retention by the bandages of Barton or Gibson.... 212 

SECTION II. 

OF THE BONES OF THE TRUNK 213 



CONTEXTS. Xvii 

SECTION III. 

OF THE CLAVICLE. 

Reduction — Treatment by the crucial bandage 213 

CHAPTER II. 

DISLOCATION'S OF THE BOXES OF THE UPPER EXTREMITY. 

SECTION I. 

OF THE HUMERI'S. 

Different positions assumed — Reduction by the heel in the axilla, 
■with the double roller towel — By relaxing the supra-spinatus and 
deltoid muscles — By the use of the pulleys, with the knee in the 
axilla — After treatment 215 

SECTION II. 

OF THE BOXES OF THE ELBOW. 

Varieties of the accident — Restoration — Subsequent treatment 220 

SECTION III. 

OF THE LOWER EXTREMITY OF THE FORE-ARM. 

Varieties — Reduction — Subsequent treatment 221 

SECTION IV. 

OF THE BOXES OF THE HAXD. 

Of the carpal and metacarpal bones —Reduction of the phalanges — 

Reduction by various methods umm ~~221 

CHAPTER III. 

DISLOCATIONS OF THE BOXES OF THE LOWER EXTREMITY. 

SECTION I. 

OF THE HIP JOIXT. 

Varieties— General plan of reduction — Restoration of each variety, 
with subsequent treatment — Restoration by means of the twisted 
r °P e ".... 221 

SECTION II. 

OF THE PATELLA. 

Varieties of the accident— Restoration and after-treatment 99Q 



XV111 CONTENTS. 

SECTION III. 

OF THE TIBIA AT THE KNEE. 

Varieties — Their mode of treatment 230 

SECTION IV. 

OP THE HEAD OF THE FIBULA. 

Reduction and subsequent treatment... 230 

| SECTIONV. 

OF THE ANKLE. 

Varieties and treatment . 231 



CHAPTER IV. 






COMPOUND DISLOCATIONS. 

Mode of treatment 232 

Apparatus for the relief of partial anchylosis 233 

PART V. 
CHAPTER It 

ON SOME OF THE MINOR SURGICAL OPERATIONS. 

On the making of incisions 235 

CHAPTER II. 

ON BLOODLETTING 241 

SECTION I. 

OPERATIONS FOR GENERAL BLEEDING. 

Phlebotomy at the bend of the arm — Choice of the vein — Prelimi- 
nary arrangements — Position of the patient — Choice of the arm — 
Of the lancet — Mode of operating with the thumb-lancet and with 
the spring-lancet — Difficulties attending the operation, and modes 
of obviating them — Mode of dressing the wound — Bleeding from 

the hand — From the ankle — From the external jugular vein 241 

Accidents attending phlebotomy 253 

Thrombus — Its causes — Treatment and mode of prevention 277 

Wound of a nerve 254 

Symptoms of the accident — Treatment 254 

Wound of an artery 255 

Mode of recognising the injury — Treatment by compression 255 

Wound of a tendon — Treatment 256 

Arteriotomy .....,., 257 



CONTENTS. XIX 

Opening of the temporal artery — Operation of Magistel — Incision of 

one of the branches, as advised by Velpeau 258 

SECTION II. 

ON TOPICAL BLEEDING. 

On Cupping — Dry-cupping — Modes of operating — Wet-cupping — 
Apparatus required — Mode of lessening the pain attending the 

application of cups 258 

On the application of leeches 261 

Modes of arresting bleeding from leech-bites 263 

Mode of preserving the leech 264 

Scarification as a means of local depletion 265 

CHAPTER III. 

ON THE MODES OF EFFECTING COUNTER-IRRITATION 266 

SECTION I. 

RUBEFACIENTS. 

Hot water — Sand — The oils, &c. — Sinapisms — Mode of their employ- 
ment — " The spice poultice" — Preparation ... f . 266 

SECTION II. 

VESICANTS. 

Boiling water — Hot metal — Steam — Spanish flies — Mode of employ- 
ing the cerate — Application of the vesicant — Treatment of the blis- 
tered surface — Mode of relieving strangury — Cases to which this 
agent is applicable — Croton oil — Its mode of action and employ- 
ment — Croton oil plaster — The strong water of ammonia — Mode 
of employment — Granville's lotions 268 

SECTION III. 

SUPPURATIVE COUNTER-IRRITANTS. 

Mineral acids — The actual cautery, &c. — Tartar emetic — Application 
of the ointment — Dressing of the surface — Tartar emetic in solu- 
tion and in plaster — Nitrate of silver — Application and uses — 
Caustic potassa — Mode of employment — Dressing of the surface — 
" The Vienna paste" — M. Canquoin's chloride of zinc paste — 
White oxide of arsenic — The actual cautery — The moxa, prepara- 
tion and employment — Issues — Their formation — Point of inser- 
tion — Setons — Composition — Mode of employment — Acupuncture 
— Operation — Electro-puncture — Uses — Vaccination — Collection 
and preservation of the vaccine virus — Modes of inserting the 
matter .- , 273 



XX CONTENTS. 

CHAPTER IV. 

METHODS OF ARRESTING HAEMORRHAGE. 

By tlie action of cold — Of astringents and styptics — Matico — By cau- 
terization, with the actual or potential cautery — By pressure with 
the hand, or tourniquet — By plugging the wound, or divided ves- 
sel — By torsion — By the application of the ligature — Mode of 
arresting epistaxis, and hemorrhage from the rectum 282 

CHAPTER V. 

ON THE DRESSING OF WOUNDS. 

Cleansing of the wound — Arrest of bleeding — Treatment of granu- 
lating wounds — Modes of securing the apposition of the edges of 
incised wounds — By adhesive strips of lead-plaster, isinglass-plas- 
ter, and by means of the solution of gun-cotton — By the inter- 
rupted suture — By the continued suture — By the quilled suture — 
By the twisted suture — By the dry suture — By invaguiated and 
other bandages , 302 

CHAPTER VI. 

ON THE INTRODUCTION OF THE CATHETER. 

Catheterism of the eustachian tube — The instrument and manner of 
introducing it — Catheterism of the oesophagus — The stomach-tube, 
and mode of using it — Catheterism of the urethra — Construction of 
the catheter, male and female, and the various plans for intro- 
ducing it into the bladder — Mode of obviating difficulties — Mode of 
securing the catheter in the bladder — Catheterism of the large 
intestine — Catheterism of the air-passages 312 

CHAPTER VII. 

ON THE ADMINISTRATION OF INJECTIONS. 

Composition of and apparatus for injections — Injections by the rec- 
tum — Syringes and mode of employment — Preparation of the 
enema — Suppositories — Injections by the vagina — Injections by 
the urethra — Injections by the lachrymal duct 327 

CHAPTER VIII. 

ON THE REMOVAL OF FOREIGN BODIES FROM THE NATURAL CANALS AND 

PASSAGES 333 

MEANS OF DIMINISHING PAIN DURING OPERATIONS. 

Administration of opium — Of the vapours of vegetable narcotics, 
and nitrous oxide gas — Inhalation of sulphuric ether and chloro- 
form vapours < 346 

APPENDIX OF FORMULA. 

Lotions— Cerates— Ointments— Liniments 350 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1 Dressing forceps 26 

2 Scalpel 26 

3 Double Catheter 27 

4 Graduated compress, from Cutler 33 

5 Pyramidal " " 33 

6 Malta cross, " , 34 

7 Treatment of epididymitis by compression, from Velpeau 37 

8 Hays' bandage for retaining dressings 41 

9 " " applied to the leg 41 

10 Arch of hoop, from South c 50 

11 Apparatus for irrigation, from Velpeau 53 

12 Portable shower-bath, from Thomson , 56 

13 " bathing-apparatus, from Thomson 59 

14 Vessel for the hip-bath, " 60 

15 Machine for rolling bandages 66 

16 Different applications of the roller, from Cutler 68 

17 Mode of making reversed turns, from Velpeau 69 

18 Crossed bandage of the elbow, from Cutler 70 

19 Recurrent bandage of the head, from Velpeau 78 

20 Four-tailed " " " Cutler 79 

21 Six-tailed " " " Velpeau 80 

22 Four-tailed " of the chin, " Cutler 81 

23 Double T " ofthenose, " " 82 

24 Monocle " from Culver 84 

25 Invaginated " of the lip, from Smith 84 

26 Purse of Pibrac for the tongue, from Velpeau 85 

27 Flexor bandage of the neck, from Velpeau 86 

28 Jorg's apparatus for wry-neck, from Cutler , ... 87 

29 Compressing bandage of the chest, from Velpeau 89 

30 Crossed " " " 90 

31 Compressing " of the abdomen, " 94 

32 Triangular " of the groin, " , , 95 

33 Cruro-inguinal triangle, from Cutler 95 

34-5 Suspensory of the scrotum, from Cutler 97 

36 Suspensory triangle, from Cutler 98 

37 Spica bandage of the shoulder, from Velpeau 101 

38 Gauntlet, from Velpeau ...... 103 

(xsi) 



XXU LIST OF ILLUSTRATIONS. 

FIG. PAGE 

39 Demi-gauntlet, from Velpeau 103 

40 Spiral bandage of the leg 106 

41 Pasteboard splint for the chin, from Cutler 122 

42 Gibson's bandage for fracture of the lower jaw, from Gibson 123 

43 Barton's " " " 123 

44 Fox's apparatus for fracture of the clavicle 131 

45 Lonsdale's apparatus for fracture of the clavicle, from Lonsdale 131 

46 Velpeau's bandage for fracture of the shoulder, from Velpeau „ 135 

47 Lonsdale's " " acromion, from Lonsdale 136 

48 Splint for fractures of the humerus, from Lonsdale 140 

49 Fracture of humerus, above the condyles, from Cooper 142 

50 " " through the condyles, from Lonsdale 143 

51 Splints for the treatment of this accident, from Cooper 144 

52 Mayo's splint for compound fractures, from Lonsdale 146 

53 Ante-brachial hyponarthecia, from Cutler 150 

54 Dupuytren's splint for fracture of the radius, from Lonsdale. ........ 151 

55 Oblique fracture of the lower end of the radius, from Fergusson.... 152 

56 Nelaton's splint for radius, from Erichsen 153 

57-8 Bond's " " " American MedicalJournal 154 

59 Hay's " " « " « 155 

60 Treatment of fracture of the olecranon process of the ulna, from 

Cooper 157 

61 Olecrano-metacarpal cravat, from Cutler 158 

62 Splint for fractures of the bones of the hand, from Lonsdale 161 

63 Double inclined plane, from Lonsdale .., 167 

64 The same applied 168 

65 Mr. Amesbury's double inclined plane, from Amesbury 169 

66 The same applied, from Amesbury 170 

67 Dr. N. R. Smith's splint, from H. H. Smith < 172 

68 M'Intyre and Liston's splint, from Fergusson 172 

69 The long splint of Desault 174 

70 Gaiter for extension, 175 

71 Cravat band for extension , 177 

72 Boyers apparatus for fracture of the thigh, from Cutler 181 

73 Liston's splint lt " " Fergusson 181 

74 Kimball and Sanborn's splint, from Miller.. 182 

75 Gibson's Hagedorn's apparatus, from Gibson 183 

76 Treatment of fracture of the great trochanter, from Cooper. 187 

77 Straight splint for compressed feet, from Erichsen...., 189 

78 Treatment of fracture of the patella, from Cooper..... 191 

79 " " " " 192 

80 Lonsdale's apparatus for the same, from Lonsdale... 193 

81 Wood splint, for fracture of the patella, from Fergusson 195 

82 Fracture-box 199 

83 A fractured leg, from Fergusson 199 

84 Fergusson's splint for fractured leg 202 

85 Suspension apparatus, from Fergusson 203 

86 Mr. Liston's splint, double plane, from Fergusson 204 

87 "Pott's fracture" of the fibula, from Lonsdale 205 

88 Dupuytren's treatment of the same, from Lonsdale 206 

89 Mode of treatment of fracture of the os calcis, from Lonsdale 209 

90 " " " " " Druitt 209 

91 Dislocation of the lower jaw, from Druitt... 212 



. 



LIST OF ILLUSTRATIONS. XXU1 



FIG. PAGE 

92 Bandage for treatment of dislocation of clavicle, from Druitt 214 

93 Reduction of dislocation of the humerus, from Cooper , 216 

94 " " " " 216 

95 Pulleys and staple, from Fergusson 217 

96 Reduction of dislocation of the humerus, from Cooper 218 

97 " " phalanx, from Fergusson 222 

98 " " " " 222 

99 "The clove-hitch," from Fergusson 223 

100 Reduction of dislocation of the thumb, from Cooper 223 

101 " " femur, " 225 

102 " " " " 226 

103 " " " " 227 

104 " " « " .'. 228 

105 " «f m from Fergusson 228 

105 Apparatus for the relief of partial anchylosis, from Mutter 233 

107 Manner of holding the knife, from Fergusson 236 

108 " " " " 236 

109 " " " " 236 

110 " opening an abscess " 237 

111 " " " " 237 

112 Plan of crucial incision, from Fergusson. 238 

113 " elliptical incisions, from Fergusson 238 

114 " variously shaped incisions, from Fergusson 238 

115 " " " " 238 

116 " " " " 238 

117 " " " " 238 

118 Incision guided by the finger, from Fergusson 239 

119 Tenotomy-knife, from Miller 239 

120 Another pattern, from Erichsen.... 240 

121 Disposition of the veins, &c, at the bend of the arm, from Wilson. 242 

122 " " " " Druitt.. 242 

123 Position of the lancet in bleeding, from Fergusson 248 

124 Bleeding from the jugular vein and temporal artery, from Telpeau. 252 

125 Plan of compressing an artery, from Miller 256 

126 Seton needle, armed, from Fergusson 277 

127 Eyed probe, as a substitute for the above, from Erichsen 277 

128 Forms of the actual cautery irons, from Liston and Mutter 285 

129 Compression of the brachial artery, from Fergusson , 287 

130 " femoral " 287 

131 The tourniquet, from Fergusson 288 

132 " applied to the arm, from Fergusson 289 

133 " « " thigh, " 289 

134 " " " popliteal region, from Fergusson... 289 

135 Field " " " arm, from Liston and Mutter 290 

136 The compressor of Dupuytren applied to the thigh, from Liston and 

Mutter 290 

137 Compressor for middle of thigh, from Erichsen 292 

138 " groin, " 292 

139 Carte's improved circular compressor, from Fergusson 293 

140 Serrated forceps, from Fergusson 294 

141 Plan of making torsion, from Fergusson , 294 

142 The toothed forceps, from Fergusson 295 

143 The tenaculum, from Fergusson , « 296 



XXIV LIST OF ILLUSTRATIONS. 

FIG. PAGE 

144 The sailor's knot, from Fergusson 296 

145 The common aneurism-needle, from Fergusson 298 

146 Physick's forceps, from Liston and Mutter 299 

147 Mode of plugging the nostrils, from Liston and Mutter 300 

148 Belloc's instrument for the same, from Liston and Mutter 300 

149 The interrupted suture, from Fergusson , 306 

150 The quilled suture, from Druitt 307 

151 Surgeons' needles, from Fergusson , 307 

152 The hare-lip suture, " 308 

153 Apparatus to aid the hair-lip suture, from Fergusson 308 

154 The invaginated bandage for longitudinal wounds, from Cutler 310 

155 Same applied, from Cutler 310 

156 Invaginated bandage for transverse wounds, from Cutler 311 

157 View of the course of the lachrymal passages, from Lawrence 312 

158 Anel's probe for dilating the lachrymal puncta and canals 313 

159 Probe for dilating the nasal duct, from Lawrence 313 

160 Morgan's probe for the same, from Lawrence 314 

161 Eustachian tube catheter, from Wilde 315 

162 Catheters for the male urethra, from Fergusson * 319 

163 Introduction of the male catheter ., 320 

164 Obstruction to catheterism from enlarged prostate, from Druitt.... 822 

165 Velpeau's mode of securing the catheter in the bladder, from Vel- 

peau . 324 

166 Double catheter and Read's syringe for injecting the bladder, from 

Fergusson * 331 

167 Mr. Wilde's ear speculum 335 

168 Wilde's gorget-like speculum auris. , 335 

169 Forceps and curette, from Wilde's Aural Surgery 336 

170 Curved forceps for the external ear, from Wilde's Aural Surgery... 336 

171 Probang, from Fergusson „ 337 

172 Removal of foreign body by the gullet forceps, from Fergusson 337 

173 Hook for removing foreign bodies from gullet, from Fergusson 338 

174 Bond's hook for removal of bodies from gullet 338 

175 Gullet forceps, from Miller 339 

176 Bond's gullet forceps 339 

177 Civiale's urethra forceps, from Fergusson.... 343 

178 Weiss' metallic urethra dilator, from Fergusson 344 

179 Scoop for removing foreign substances from the rectum, from Fer- 

gusson 345 

180-181 Inhalers, from Pereira.. 348 



MINOR SURGERY. 



PART I. 



The means employed by the surgeon in the treatment of 
the diseases to which he is ordinarily called, should first 
engage our attention : they are, in a measure, of a mechanical 
and chemical kind. This part of the volume will therefore be 
devoted to the consideration : 

First. Of the instruments which it is most necessary to 
provide for daily use. 

Second. Of the materials employed for surgical dressings, 
and the mode of applying them, — including the use of water 
as a local application, and for bathing. 

Third. Of the means of purifying the atmosphere of the 
patient's apartment. 



CHAPTER I. 

ON THE INSTRUMENTS USED IN DRESSING. 

The instruments which the daily avocations of the surgeon 
call for are of various kinds. For convenience-sake they are 
arranged in a " pocket-case. " They may be multiplied 
according to the fancy of the surgeon ; but those which will 
be found most useful are, the dressing and dissecting forceps, 
a pair of scissors, bistouries, scalpels, a thumb-lancet, an 
abscess lancet, a director, probes, a tenaculum, curved needles, 
a porte-caustic, a double catheter, and ligatures. 

3 (25) 



26 INSTRUMENTS USED IN DRESSING. 

The uses of the dressing forceps are manifest, in the re- 
moval of oiled dressings, covered, as _ they very often are 
S acrid and irritating secretions; in the loosening and 
Ti hdrawal of decayed bone, and other foreign matters, from 
Onuses deep wounds, and such points as are of difficult access 

o the finge?s alone.' For such purposes the common dissect- 
iL forceps will frequently answer. But the proper Dressing- 

ffrtp Ts of a more suitable shape, as illustrated by the ac- 
Smpinying drawing (fig. 1). A still better form is that of 

Fig. 1. 




the French Polypus-forceps, the blades being bent in^ front 
of the pivot, so that the instrument occupies less space m the 
■wound or sinus, when opened than when closed. 

The scissors used by the surgeon may be straight or 
curved. 

There should be two bistouries in the pocket-case : a 
sharp-pointed and a probe-pointed. The circumstances m 
which each will be most advantageously employed, will rea- 
dily suggest themselves to the operator. 

There is great variety of opinion as to the best form and 

Fig. 2. 




size for the Scalpel Mr. Fergusson prefers one of the shape 
and dimensions indicated in the annexed drawing (fig. 2), the 
blade and handle together being about six inches long. With 
such a scalpel in his pocket-case, one may perform almost any 



INSTRUMENTS USED IN DRESSING. 



27 



Fig. 3. 



i 



of the capital operations of surgery, so far as mere cutting is 
concerned. 

The director and the probes should be of silver, as being 
flexible, and less liable to be injured by contact with the 
various fluids with which they will meet, than if made of steel. 
The probes should be of various sizes, and one should be made 
with an eye in its flattened extremity, for the purpose of being 
armed, if occasion require, with a ligature, a skein of silk, or 
a piece of tape. 

The porte-caustic should be 
of platinum, as this metal best 
resists the action of nitrate of 
silver, which is the caustic ge- 
nerally carried in the pocket- 
case. The platinum cup may 
be fitted to a stem of wood, or 
it may be so made as to be re- 
ceived into a silver case ; the 
latter is the best arrangement. 
In addition to the lunar caustic, 
the surgeon will find it conve- 
nient, oftentimes, to have a 
crystal of the sulphate of copper 
in his case. 

The double catheter is made 
of silver, as is the common male, 
or female, catheter. It con- 
sists of three pieces, as repre- 
sented in the annexed drawing, 
(see fig. 3.) A, a straight tube, 
about five inches long, having 
at its upper extremity two rings 
firmly soldered to the tube at 
points opposite to each other ; 
while the lower extremity has a 
female screw-thread cut upon it, 
of half an inch in length : B, 
a beak, an inch and a half or 
two inches long, slightly curved, 
its lower extremity closed and 
rounded, while the upper end is provided with a male screw, 




28 INSTRUMENTS USED IN DRESSING. 

corresponding with the female screw of the staff which is in- 
tended to receive it. Just above the lower extremity of this 
beak, two oval or rounded fenestra are cut, one on each 
side, thus throwing open the cavity : C, another beak, about 
seven inches. long, having a curve similar to that of the or- 
dinary male catheter, and its upper and lower extremities 
adjusted as are those of the shorter beak. By simply 
screwing the short curved piece to the staff, we have an ele- 
gant female catheter ; by similarly attaching the long curve, 
a male catheter. When in the pocket-case, the short' beak 
should be kept screwed to the staff. 

This instrument is very well made by Mr. Warner of this 
city, Commerce Street. The tube should be thicker and 
stronger than that of the ordinary catheter, and care should 
be used that the joints be accurately fitted. 

The advantages of having so important an instrument as 
this reduced to a form so portable, need not be insisted upon. 

In addition to the instruments above enumerated, the 
pocket-case may be made to include a spatula, a double canula 
with its wire, a seton-needle, and a razor. These, however, 
are not so essential elements of the case, as those before 
mentioned ; generally they can be dispensed with, or other 
instruments may well be used in their stead ; and their pre- 
sence will render the pocket-case much more bulky and 
cumbersome. 

The blades of the bistouries and scalpels may be so made 
as, when not in use, to be concealed within the handle, as the 
blades of the ordinary pocket-knife ; by this arrangement, 
the edge of the instrument will be protected from injury. 



CHAPTER II. 

ON SURGICAL DRESSINGS. 

The various appliances used in surgical dressings may be 
thus enumerated: lint, cotton, tow, compresses of various 
kinds and forms, sponge-tent, setons, adhesive and other plas- 
ters, poultices, lotions, cerates, ointments, liniments, bandages, 
sponge, and apparatus of various kinds, more or less complex, 
for special purposes. Some description of each of these will 
be necessary. 

1. Lint is the soft fleecy substance obtained by unravelling 
old linen. It may be procured in the shops in the form of 
what is called " patent lint," or it may be prepared as required 
for use, by scraping, with a sharp knife, the surface of old 
linen, previously put upon the stretch. The linen selected for 
its preparation should be soft, from use and washing. As 
thus obtained, the lint is very light and delicate, and admi- 
rably adapted to absorb the secretions of parts to which it 
may be^ applied. The " patent lint" is sold in sheets or rolls, 
one of its surfaces is fleecy, the other is smooth : its texture 
is compact, certainly not nearly so porous as the loose lint ; 
hence it absorbs much less readily and freely than the latter. 
Both varieties of lint are applied dry, or covered with cerates, 
or saturated with some kind of lotion. 

The French surgeons employ an admirable sort of lint, 
which they term "charpie" It is now very generally used 
in this city, and, indeed, throughout the country, when it can 
be procured. It is thus made : — linen, of a coarse or fine tex- 
ture, according to circumstances, is cut into small pieces, a few 
inches square, and its tissue completely unravelled, thread by 
thread. The coarser kind of charpie may be made of old 
table-cloths; the finer sort of a lighter material. Velpeau 
gives a decided preference to charpie made of old linen, as 
being much more absorbent, and much less irritating, than 
that made of the new fabric. 

(Charpie of an excellent quality is made in this city by Mrs. 
3 * ( 29 ) 



30 SURGICAL DRESSINGS. 

Jones, southwest corner of Walnut and Juniper streets, and is 
kept for sale in many of the apothecary shops.) 

Lint, in its various forms, is used as a simple application to 
ulcerated or excoriated surfaces ; to favour an equable and 
even pressure upon any part ; to prevent adhesion between the 
walls of cavities, natural or accidental ; to absorb various se- 
cretions, and as a vehicle by which medicinal applications may 
be made, when and wherever required. 

Various arbitrary terms have been applied to no less arbi- 
trary forms, which lint, and especially charpie, may be made 
to assume, as an element of surgical dressings. Thus, there 
is the plumasseau or pledget, the roll, the bullet, the mesh, 
the tent, the tampon, the pellet, &c. 

The plumasseau is prepared by simply folding, at the mid- 
dle, a sufficient number of the filaments of charpie, previously 
laid parallel to each other. For the sake of neatness, the 
ends of the threads may be cut off evenly, or inverted, and 
the mass thus formed moulded by the hands to any shape, flat, 
round, circular, square, or oblong, to adapt it to particular 

The roll is a mass of charpie, rendered cylindrical by the 
hands, and firmly tied at the middle. It is chiefly used to ar- 
rest hemorrhage, by pressure, from a deep-seated vessel, or to 
absorb the secretions from wounds or cavities. For conveni- 
ence in withdrawing the mass, the string, tied about the mid- 
dle, may be left attached at this point, and projecting from 

the orifice. 

The term bullet is applied to a small mass ot charpie or 
common lint, rolled into the form of a small ball. A number 
of these may be advantageously used for the same purposes 
as the roll just described. t m 

The mesh resembles the roll very much m its uses ; its 
fibres are left loosely floating, instead of being rolled together. 
It is sometimes employed in the treatment of sinuses and 
fistulous canals, by being thrust to the bottom of such cavi- 
ties, on the end of a probe, with the view of preventing their 
healing at the orifice. It may be introduced dry, or covered 
with some lotion or cerate, more or less stimulating. 

The tent of charpie is made by twisting a certain amount 
of this substance into the form of a cone. For the purposes 



SURGICAL DRESSINGS. 31 

for "which a tent is generally required, it is very much inferior 
to the sponge-tent. 

The tampon is merely a large ball of charpie, or it may 
be a number of bullets. It is used in the plugging of bleed- 
ing wounds, &c. 

The pellet consists of a ball of charpie or common lint, 
enclosed in a piece of soft linen, firmly tied. It may be used 
as a tampon. 

■ The good sense of the surgeon or dresser will enable him 
to employ these different forms of lint seasonably, or to 
invent others still better. 

2. Cotton may be used with advantage in many cases. 
Its cheapness — and the almost universality of its diffusion — 
are of themselves great recommendations, in connexion with 
its softness, lightness, and the porosity of its texture. It is 
sold either as "carded cotton,'' or, in the form of "sheet 
cotton,'' in large sheets, of which both surfaces are smooth, 
more or less glazed, forming, as it were, thin pellicles, between 
which the true cottony mass is inclosed. As an application 
to secreting surfaces, it will be found to be less absorbent than 
lint, and probably more irritating. It is very much employed 
as a covering to extensive superficial burns, to protect their 
sensitive surface from the action of the air and other irritants. 
But when there is much suppuration or other discharge, the 
cotton, becoming more or less imbued with the secretion, is 
heavy and heating, and is readily displaced by slight move- 
ments of the patient, becoming rolled into hard masses. 
Probably every dresser has been often much annoyed, by the 
difficulty which he has experienced in removing from a large 
moist sore, these numerous indurated pellets of cotton, which 
sometimes adhere very tenaciously to the granulations. Its 
chief uses — and for these it is almost invaluable — are, to 
form a soft bed in which an injured part may be reposed, to 
prevent unpleasant pressure and excoriation from bandages 
and other apparatus, and to envelope parts, of which the 
natural temperature has become depressed. 

3. Tow is never applied directly to a secreting or abraded 
surface ; being too harsh and irritating. It is made use of 
in enveloping other dressings in cases of profuse discharges, 
as in compound fractures, suppurating stumps, &c. 

4. The compress is employed for a variety of purposes. 



32 SURGICAL DRESSINGS. 

As the name imports, it was at first used to effect, or to fa- 
cilitate, pressure upon any part ; now, however, it has acquired 
a wider application, being equally adapted to the covering 
and protection of injured surfaces; to retain other dressings, 
and to give regularity and symmetry to the form of a limb, 
or of any other part, to which a bandage is to be applied. 

Compresses may be made of various materials, as linen, 
muslin, woollen fabrics, lint, cotton, tow, &c. When intended 
for direct application to secreting surfaces, they should be 
of lint or soft linen, and applied dry or anointed. The ad- 
vantages of a flannel compress are, its elasticity, its warmth, 
and the readiness with which it imbibes any moisture of the 
surface. The cheapness of the different fabrics of cotton 
recommends them for many purposes ; for wherever economy 
may be properly consulted, without conflicting with more im- 
portant considerations, the surgeon, whether in hospital or in 
private practice, should not fail to be influenced by it in the 
choice of the material for his dressings. Whenever a com- 
press is to be employed external to other dressings, or upon 
an uninjured surface, it may, as a general rule, be formed of 
cotton stuffs, as properly as of linen. 

For convenience, accuracy, and neatness of application, 
compresses are made of divers forms and shapes, to suit par- 
ticular cases and indications ; Velpeau's division is a very sim- 
ple one, into the plain, the divided, and the folded. The most 
important are, the square, the graduated, the perforated, and 
the split compresses. 

The square compress is sufficiently well described by its 
name, as are also the oblong and the triangular compresses ; 
their size and thickness may vary at the pleasure of the sur- 
geon, and with the requirements of each case. 

The graduated compresses are so contrived as that they 
shall present a gradually diminishing surface at the summit, 
as their thickness increases. 

The common graduated compress may be made by taking a 
strip of any material of the required width, and folding it 
upon itself so that each successive fold shall be shorter than 
the one which preceded it. By thus regulating the length of 
the folds at one end only, the single graduated compress is 
made (fig. 4) ; by pursuing the same plan at both extremities, 
the double graduated compress. The pyramidal compress is 



SURGICAL DRESSINGS, 



33 



Fig. 4. 



Fig. 5. 




formed by piling successively on each other pieces of any ma- 
terial, of gradually and regularly dimi- 
nishing size, — of square, oblong, or circu- 
lar shape (fig. 5). 

These varieties of the compress are 
useful when firm pressure, made generally 
with the aid of a bandage, or of the hand, 
is required upon some deep-seated point, 
as, for example, to arrest the circula- 
tion through a bleeding vessel. 

The perforated compress, as its name 
indicates, is one in which an aperture has 
been cut. The number of such aper- 
tures may vary indefinitely. A very ele- 
gant dressing to a suppurating surface consists of a compress, 
or a simple piece of linen, perforated in a cribriform manner, 
and spread with cerate of some kind. The pus has in this 
way free escape, and may be absorbed by lint laid upon this 
sieve-like covering. 

The chief varieties of the split compress, are the retractor 
of two and of three tails, and the Malta cross. 

The retractors are formed by making one or two longitudi- 
nal slits (as two or three tails are required) in a piece of mus- 
lin three or four inches wide, and two and a half feet long. 
They are used in amputations to draw up the soft parts, after 
the incision has been made, for the purpose of protecting them 
from the saw, while the bone is being removed as high up as 
the incision of the soft parts will allow. The retractor of two 
tails is employed in amputations of the arm and thigh ; the 
other in the removal of the forearm and leg. In its applica- 
tion, the former is made to grasp the bone between its tails, 
which are then drawn upwards beneath the member, the body 
of the retractor being carried in the same direction along its 
superior face ; the soft parts are thus enclosed and shielded 
between the two. In using the retractor of three tails, the 
middle tail is thrust between the two bones of the leg, or fore- 



arm. 



To prepare the Malta cross, (fig. 6), take a square piece of 
linen or patent lint, of the required size, and fold it through 
the middle of one of its sides ; double the oblong thus formed 
upon itself through the centre of one of its longitudinal dia- 



34 



SURGICAL DRESSINGS. 



Fig. 6. 




meters, and from the free angle of the smaller square thus 
produced, (the angle at which the vari- 
ous laminae composing the square are se- 
parable), make an incision along its ob- 
lique diameter, to within a short dis- 
tance of the opposite angle. When the 
square is re-opened, it will present the 
form of the Malta cross. It is used as 
a direct application to stumps, having 
been previously perforated at numerous 
points, and spread with cerate. 

The half Malta cross is made by fold- 
ing an oblong piece of linen, or patent 
lint, through the middle of its longitudi- 
nal diameter, and continuing an incision from one of its free an- 
gles, along the oblique diameter, nearly to the opposite angle. 
Its uses are as those of the last described. 

5. Sponge-tent is prep.ared by thoroughly saturating soft 
sponge with melted beeswax, or gum tragacanth, and subject- 
ing it to pressure as it cools. It is employed for the purpose 
of dilating wounds, fistulous canals, &c, which it effects by 
imbibing moisture from the cavity, and thereby swelling. For 
use, a piece of the hardened mass of sponge is cut of the re- 
quisite size and form, and gently introduced into the cavity, 
where it may be easily confined by a piece of adhesive plaster 
stretched across the orifice. 

It is well to recollect that the prolonged retention of a 
sponge-tent, particularly in irritable patients, frequently ex- 
cites violent pain, swelling, and heat in the part, accompanied 
often with considerable fever. In such cases, these effects 
speedily disappear upon the removal of the tent, followed or 
not by the application of some soothing dressing, as warm 
water, or a poultice. 

6. Setons are made of a variety of materials : as of a skein 
of silk, a piece of linen tape, or a piece of ordinary soft linen, 
which has been unravelled along its borders. 

7. Adhesive plaster, is composed of some substance or 
substances, possessed of tenacious or adhesive properties, and 
susceptible of being spread upon linen, muslin, or some similar 
material. 

The " emplastrum resinse," of the U. S. Pharmacopoeia, is 



SURGICAL DRESSINGS. 35 

the one generally employed in this country. It is sold in the 
shops already spread upon linen or muslin. (The adhesive 
plaster made by Charles Ellis, of this city, is particularly ex- 
cellent.) 

Adhesive plaster is one of the most indispensable articles of 
dressing to the surgeon. Its uses are numerous. 

Its most frequent employment is in the approximation of 
the lips of wounds. For this purpose, the plaster should be 
cut into strips, varying in width according to circumstances, 
but, for neatness-sake, the strips intended for the same dress- 
ing should be of equal width. In cutting them, the sheet of 
plaster should be made tense by the hands of the surgeon and 
an assistant, while the former forces a pair of sharp scissors, 
without closing the blades, across the sheet parallel with the 
course of its threads; in this way the strips may be cut 
straight and very rapidly. 

For application, the strip should be warmed, by being held 
near a fire ; or, which is much better, by wrapping its un- 
spread surface around a vessel containing boiling water; the 
wound having been carefully cleansed, and the surrounding 
surface washed and dried, and freed from hair, one extremity 
of the strip is placed upon the skin at a suitable distance 
from the edge of the wound, — the distance varying according 
to the degree of force which shall be requisite to retain 
the edges in contact, — the edges themselves are accurately 
approximated by the fingers of the dresser, and the strip is 
drawn across them, and pressed all along its course upon 
the skin. 

If the wound is so long as to require the application of two 
or more strips, spaces should be left between them, to permit 
^he escape of fluid. 

The length of time during which the plaster should remain 
must vary in different cases. Generally, the strips should not 
be disturbed until the wound has cicatrized, or until its edges 
are somewhat firmly agglutinated, unless they shall have be- 
come previously loosened from accidental causes, or productive 
of some unpleasant effect. 

^ In removing the dressing, the portions of the strip on each 
side of the wound should be raised alternately, and fresh 
pieces applied as soon as possible, if the same dressing is to 
be continued. Where a wound is traversed by more than 



36 SURGICAL DRESSINGS. 

one strip, a fresh one should take the place of each, as it Is 
removed, before a second is withdrawn. This precaution is 
necessary, in order that the delicate adhesions of the lips of 
the wound shall not be destroyed or weakened. 

Many years ago, Mr. Baynton, an English surgeon, recom- 
mended the employment of adhesive plaster in the treatment 
of ulcers. The plaster which he used was composed of six 
drachms of resin melted with a pound of lead plaster. He 
directed that the ulcer be first carefully cleansed, and the 
surrounding surface denuded of hair ; that adhesive strips, 
two inches wide, and of sufficient length to encompass the 
limb, and, in addition, to extend four or five inches over the 
edges of the ulcer, be passed around the leg, from an inch 
below to two or three inches above the sore, and with suffi- 
cient force to approximate slightly its edges, — each successive 
strip being in contact with that last applied ; that compresses 
of soft calico be placed around the limb, and the whole enve- 
loped with a bandage from the toes to the knee. If there 
should be much heat or pain in the limb, cold water may be 
applied over the dressing. This treatment is best adapted to 
chronic indolent ulcers, attended with swelling and induration 
of the limb. As the tumefaction abates, the dressings are 
to be applied more tightly: they should be changed more or 
less frequently, according to the greater or less amount of 
suppuration, from twice in twenty-four hours, to once every 
three or four days. According to the experiments of Velpeau, 
Boyer, Roux, and others, ulcers are cured more speedily by 
this method of treatment than by any other ; walking about 
on the limb, moderately, facilitates the cure. Boyer found 
that the average length of treatment by this mode, calculated 
from a large number of cases, was twenty-six days ; while, ac- 
cording to Duchatelet, of 690 cases treated by the ordinary 
methods, the average duration of treatment was fifty-two anc 
a half days. (Cutler, pp. 210, 211.) 

The ordinary adhesive plaster of the shops will very wel 
answer the purpose of that employed by Baynton. Previous 
to its application, the limb, from the toes to within a few 
inches of the ulcer, should be enveloped by a roller, which is 
to be continued over the whole leg after the other dressings 
have been applied. 

In the drawing, fig. 40, this method of treatment is illus- 



SURGICAL DRESSINGS. 



37 



trated, the upper part of the ulcer being purposely left ex- 
posed. 

The same plan of treatment has been extended, by Vel- 
peau, Boyer, and Roux, to all ulcers which have become 
atonic or chronic, and by the former of these distinguished 
surgeons, particularly, to burns (Velpeau, M£d. Op£rat., 
vol. i., p. 257), and also to varicose and ganglionary tumours, 
&c, &c. 

M. Fricke, of Hamburgh, first called attention to the effi- 
cacy of compression, methodically and carefully made by 
strips of adhesive plaster, in the treatment of epididymitis. 
They may be thus applied : the scrotum should be carefully 
cleansed, and the hair shaved from it; the testicle is then 
forced to the bottom of the sac, and the affected side of the 
scrotum, clasped just below the ring by the thumb and fore- 
finger of the left hand, is surrounded by a very narrow strip 
of plaster, which is then carried down over the scrotum in 
such a way as to apply itself neatly and smoothly to the 
skin ; successive strips are used, until the part is entirely en- 
veloped. The pressure should be moderate and regular. As 
the swelling subsides, the strips will of 
course become loose, when they may be re- 
moved, and fresh ones applied as before. 
If there be much pain, the employment of 
the adhesive plaster may be preceded by the 
application of leeches over the scrotum it- 
self, or in the groin. 

Chronic indurations generally of the 
testicle are very often removed or dimi- 
nished by this treatment. The annexed 
drawing illustrates this application (fig. 7). 

It will frequently be found that, after 
the removal of adhesive strips from the 
surface of the body, a portion of the ad- 
hesive matter remains upon the skin ; 
water alone will not easily remove it, but 
gentle rubbing with a sponge moistened 
with spirit of turpentine, will readily 
cleanse the part. The black discoloration 
often noticed is a matter of no consequence ; it is simply owing 




38 SURGICAL DRESSINGS. 

to the action of the matter of the secretions of the surface 
upon the lead plaster. 

Several objections have been urged against the employ- 
ment of the common adhesive plaster ; some of them are well 
founded, others not so. It sometimes, though by no means 
usually, irritates the skin, producing an erythematous inflam- 
mation, and occasionally a papular or a vesicular eruption ; 
this is particularly the case when the application is made to 
the skin of young children and infants. To avoid such in- 
conveniences, the " isinglass plaster" has been recommended 
as a substitute for the other. It is prepared by spreading 
upon oiled silk, or silk glazed on one side only, and on the 
unglazed side, a solution of Isinglass in Spirit (Liston). When 
dry, the silk may be laid aside until required for use, then it 
is cut into strips of the desired width, and its adhesive sur- 
face softened by the application to it of a hot moist sponge ; 
the strips are to be employed as directed for the ordinary 
adhesive plaster. The advantages of this preparation are, 
its cleanliness, its perfectly unirritating nature, and its trans- 
parency, whereby the surgeon is enabled to see the condition 
of the surface upon which it is applied, without removing 
the strips. It is, however, less adhesive than the common 
plaster; for, as has been well observed by Dr. Smith 
(" Minor Surgery," p. 38), the warm discharges from the 
part to which the isinglass plaster is applied, soften its mate- 
rial, as did the hot moist sponge. Therefore, whenever con- 
siderable tenacity of adhesion is requisite, the ordinary plaster 
is preferable. 

(The isinglass plaster is made in this city by Mr. Hus- 
band, Apothecary, Spruce Street.) 

" Collodion," an ethereal solution of gun-cotton, will be 
found to be a very convenient adhesive material. To apply 
it, lay strips of muslin or linen across the wound, the edges 
of the latter having been accurately approximated, and satu- 
rate them with the collodion by the aid of a camel's-hair 
pencil. The strips should be made of some unglazed fabric, 
as this imbibes the solution more readily and thoroughly than 
the glazed. 

In slight wounds the strips may even be dispensed with, 
the liquid being merely painted over the surface, the edges 
of the wound being held together until the collodion is dry. 



SURGICAL DRESSINGS. 39 

The contractility of this substance 13 such that it has been 
recommended as a means of curing small ncevi, by the com- 
pression which it induces in drying. 

Various other plasters are frequently employed by the 
surgeon. 

The soap plaster — "Emplast. Saponis," — spread upon soft 
sheepskin, and then cut into strips, or into pieces of any 
shape and size, will be found oftentimes to answer a very ad- 
mirable purpose, in making pressure upon an enlarged joint, 
or an indolent tumour, &c, &c. It is very mild and unirri- 
tating, and preserves the integuments soft and moist, and is 
an excellent preventive of excoriation. 

The mercurial plaster is very commonly employed as a re- 
solvent of tumours, and other indurations. The belladonna 
plaster is an excellent anodyne application. 

Plasters should be smoothly and evenly spread on coarse 
muslin, or stiff brown paper, or, which is much the best ma- 
terial, on soft sheepskin. A piece of skin, or other material, 
should be cut of a shape suitable for application to each par- 
ticular part, and rather larger than the surface intended to 
be covered by the plaster ; a narrow strip of paper may be 
then pasted around its margin, and within the space thus 
bounded, the plaster is to be spread, after which the paper 
may be removed. In order that it may adapt itself smoothly, 
accurately, and neatly to the surface, it is well to make 
several slits from the margin of the plaster towards its centre. 

8. One of the most common articles of dressing, both in 
domestic and professional practice, is the poultice. When 
badly made, it is undoubtedly deserving of the abomination, 
with which it is so amusingly and feelingly regarded by Mr. 
Liston; but when properly prepared, and correctly used, it 
cannot, we think, be conveniently dispensed with for any 
other substitute whatever. 

The poultice should be always soft and moist, and these 
requirements should be kept in view, as far as possible, in 
the choice of the materials of which it is to be made. The 
substance which is to form its basis is generally in the form 
of a powder ; this should be stirred about with sufficient water 
to give to the mass a soft consistence, yet not so moist as to 
permit the fluid to flow from it. The water may be cold or 
hot, according to circumstances, and may be best incorpo- 



40 SURGICAL DRESSINGS. 

rated with the powder by adding sma,ll portions of each al- 
ternately and successively. The semi-solid mass thus pre- 
pared may be spread upon a piece of muslin smoothly and 
evenly, by the aid of a wooden or iron spatula, or an ordinary 
table-knife ; it should be from a fourth to half an inch thick, 
and occupy just so much of the surface of the muslin as that 
the margin of the latter may be reflected upon it, all around, 
for the space of half an inch ; this latter arrangement gives 
to the poultice a very neat and elegant appearance, and fa- 
cilitates very much its removal from the surface to which it 
may have been applied. 

Some surgeons prefer to protect the part from immediate 
contact with the poultice, by the intervention of a piece of 
fine cambric or gauze, previously laid upon the surface of 
the latter. For so doing, they urge that, otherwise, portions 
of the poultice remain adherent to the skin or ulcer, after 
the mass has been removed, and are displaced with some dif- 
ficulty and occasional pain to the patient. If, however, the 
poultice has been properly prepared and applied, and not too 
long retained, this annoyance will rarely occur. Moreover, 
by thus covering the poultice, we are deprived, in a great 
measure, of the benefit derivable from the direct contact of 
its materials with the affected part ; and this consideration is 
an important one oftentimes, as, for example, when the poul- 
tice is medicated; for, as Velpeau remarks, " poultices are 
not intended to act merely as compresses saturated with warm 
water." Yet when the application is intended for the eye, 
or the neighbourhood of the nostrils or mouth, or when it 
contains ingredients which may be too irritating for the sound 
skin, it is very proper to use the precaution alluded to. 

Generally, the smearing of the poultice with oil, or grease 
of any kind, is unnecessary and objectionable. 

In order to retain the warmth and moisture and softness of 
the poultice as long and as completely as possible, it should 
alwaj^s be covered externally with a piece of oiled silk, or thin 
India-rubber cloth ; the unpleasant odour of the latter, how- 
ever, renders the first a preferable application* 

This dressing should be changed at least twice daily; and 
when the discharge is profuse, in warm seasons, when the 
poultice is very soon soured — or when the speedy production 
of suppuration, or the relief of great pain is desired, the ap- 



SURGICAL DRESSINGS. 



41 



plications should be renewed as often as every two or three 
hours, or even still more frequently. 

In removing it, the poultice should be gently drawn up by 
one side, and reflected upon itself gradually, until the whole 
is lifted up ; if it adhere at any point, its detachment will be 
easily effected by allowing a little warm water to trickle over 
the part ; before applying a fresh dressing, the surface should 
be carefully and gently cleansed. 

To retain the application in its place, a roller may be passed 
around it, extending a short space both above and below it. 
But it often occurs that the part to which the poultice is ap- 
plied, whether it be an irritable ulcer or otherwise, is too ten- 
der and painful to bear the agitation to which it must be sub- 
jected in the use of the roller ; in such cases the " bandage 
of Scultetus" should be employed; thus, the entire dressing 
may be renewed without moving the suffering part. 



Fig. 8. 



Fig. 9. 




Dr. Hays, of this city, is in the 
habit of making use of a bandage, 
in similar cases, which may be con- 
sidered as a modification of the 
many-tailed bandage ; its simplicity 
and perfect adaptation to this and 
numerous other analogous pur- 
poses, renders it worthy of descrip- 
tion. 

A piece of muslin more than 

wide enough to envelope the part, 

as the leg, for instance, and rather 
4* 




42 Surgical dressings. 

longer than the poultice, or other application which it is in- 
tended to retain, is cut or torn, transversety from each mar- 
gin, leaving a central space entire, of some few inches in 
breadth ; this is laid on the pillow or bed, and the leg, with 
the poultice applied, is placed upon it; then, commencing 
from below, the tails, first on one side and then on the other, 
are alternately and successively brought over, as the strips of 
the bandage of Scultetus, and the last two tied in a single or 
double bow-knot. This simple bandage will be found very 
useful in retaining blisters, cerates, or any similar application, 
upon parts too sensitive to admit of much disturbance : figs. 
8, 9, exhibit this bandage, free, and applied. 

If the discharge is at all profuse, it should be absorbed as 
soon as possible by cotton, tow, or some similar substance, 
arranged to receive it. Thus if the arm be the part affected, 
it should be laid upon a pillow (the patient being in bed), pro- 
tected by a piece of oil-cloth, upon which some tow or bran 
has been placed ; the same disposition may be made with the 
leg ; or this member may be conveniently put in a fracture- 
box filled with bran, or containing a pillow protected as be- 
fore. In order to preserve the bed-clothes from contact with 
the discharged matter, a semi-circular framework of wire or 
bamboo, should be thrown over the limb. (See fig. 10.) 

The material of which the poultice shall consist must vary 
with the indications to be fulfilled in each case. It may be 
emollient, refrigerant, astringent, stimulating, or anodyne. 

The emollient poultice, as its name implies, is made of per- 
fectly bland and unirritating material. The materials of 
which it is usually prepared, are bread and milk, bread and 
water, and water with corn-meal, flaxseed meal, or slippery 
elm powder. Each surgeon, probably, has some fancy of his 
own with regard to what forms the best poultice, some pre- 
ferring this, some that material. Abernethy, who seems pro- 
foundly to have studied the philosophy of poultices, gives 
decided preference to the bread and water, and the flaxseed 
meal poultices ; after detailing the mode in which the latter 
should be prepared, he exclaims, rapturously: " When thus 
made, oh ! it is beautifully smooth ; it is delightfully soft ; it is 
warm and comfortable to the feelings of the patient/' (South's 
"Hints on Emergencies," p. 12.) 

The bread poultices, made either with milk or water, be- 



SURGICAL DRESSINGS. 43 

come dry and stiff sooner than those prepared with flaxseed 
meal ; the latter contains a considerable portion of oil, which 
imparts great softness to the mass when w T et ; but it also gives 
it a not very pleasant odour, and in warm weather, or when 
long in contact with an inflamed surface, it soon becomes 
rancid and irritating; upon some skins, moreover, it pro- 
duces a vesicular eruption. Perhaps the poultice least lia- 
ble to objection, is that made of the powder of slippery elm 
bark. 

The above-named poultices when applied cold may be 
termed refrigerant. An application of this kind may be 
prepared by employing a solution of acetate of lead, in the 
proportion of 3ij. or 3iij. to a pint of water, instead of simple 
water, in mixing the poultice. In order to increase their 
cooling effect, they may be applied without covering them 
with oiled silk or any bandage, so that evaporation shall be 
unchecked. It must be recollected, however, that although 
cold when first laid upon the part, they soon acquire the same 
temperature as the surface ; they require, therefore, frequent 
renewal. 

Astringent poultices may be made by incorporating any 
powder of astringent property, with some one of the mate- 
rials already mentioned. The substances most frequently 
used are powdered oak bark, galls, and alum. A very elegant 
poultice of this kind is prepared by rubbing up alum with the 
white of egg. 

Stimulating poultices are formed in the same way, by in- 
corporating stimulating substances with some sort of meal, 
and water. With this view the scrapings of carrot, or horse- 
radish, are employed. Solutions of chloride of lime, or of 
soda, of creasote, or of common soap, are often used ; or a 
poultice may be made of stewed onions. One of the best 
and most agreeable of the stimulating poultices is the cam- 
phor poultice, made by incorporating spirits of camphor with 
the meal or other substance used as the basis. It is particu- 
larly serviceable as an application to gangrenous parts, slough- 
ing ulcers, &c. 

The fermenting poultice is made by incorporating yeast, or 
porter, with corn meal, and is of great advantage in hastening 
the separation of gangrenous parts. A very common prepa- 
ration of this sort is the ordinary mustard poultice. These 



44 SURGICAL DRESSINGS. 

applications are employed when a decided irritant or stimu- 
lating effect is indicated. 

An anodyne poultice may be made by stewing bruised 
poppy-heads until they become somewhat soft and adhesive; 
or the dregs of opium, left after the preparation of laudanum, 
or this liquid itself, may be mixed with meal ; or the bruised 
leaves of belladonna may be moistened, and applied. The 
leaves of the tobacco plant moistened, may be used in the 
same way, but their application should be carefully watched, 
lest too great prostration ensue. Hops, or chamomile- 
flowers, enclosed in a flannel bag wrung out of hot water, or 
incorporated with meal or bran and hot water, form an ex- 
cellent anodyne poultice. 

Medicated poultices may be very elegantly prepared, by 
making an infusion of the substance, whatever it be, which 
has been selected as a medicament. Poppy-heads, the carrot, 
potato, horseradish, various astringent substances, may be 
simmered for an hour or two in a closed vessel containing 
water, and the liquor, after having been strained, incorporated 
with meal of some kind. (South, p. 11.) 

Mr. Liston, and some others, object altogether to the use 
of poultices, proposing to substitute water, medicated or 
simple, cold or w T arm. For this purpose, some one of the 
infusions above mentioned will answ r er very well. They should 
be applied by means of linen, lint, or flannel, several times 
folded, and saturated with them, thus constituting fomenta- 
tions ; they should be kept constantly upon the part. To be 
of real benefit, their employment demands assiduous and un- 
intermitting care from the attendants, much more, indeed, 
than can be generally expected or obtained, particularly in 
hospitals ; this constitutes a serious objection to their being 
generally used as substitutes for poultices. Neither do they 
supply the same body of heat as the latter, when heat is re- 
quired. They are, however, more cleanly than the poultice, 
and this seems to be their chief advantage — an important one 
truly. Where a cold application of this sort is desired to 
reduce the temperature of a part, the most effectual is 
pounded ice, with which a bladder, or a bag of India-rubber 
cloth, may be partially filled : the temperature of the appli- 
cation will remain as low as 82° F., so long as any particle 
of ice remains unmelted, after which the water in the sac will 



SURGICAL DRESSINGS. 45 

gradually acquire the temperature of the part to which it is 
applied ; hence the hag must be examined from time to time, 
and the ice renewed when necessary. Sacks, intended ex- 
pressly to hold water, are made of thin India-rubber cloth ; 
one of these may be partially filled with water containing 
various^ saline substances which, during their solution, ab- 
stract its heat ; this forms a very good substitute for the 
bladder of ice, when ice cannot be obtained. One ounce of 
nitre, one ounce of sal ammoniac (chloride of ammonium), 
and half a pint of water, may be thus employed. (Thomson' 
"Management of the Sick Room," p. 277.) 

These applications, whether used in the form of poultice 
or of fomentation, fulfil a variety of indications. When 
employed warm, they relieve spasmodic pain, or sometimes 
continued pain ; produce or promote suppuration ; allay irri- 
tation frequently, and sometimes inflammation : diminish oede- 
matous enlargements, by promoting local perspiration, or 
transpiration ; induce resolution of acute or chronic inflamma- 
tions and indurations, &c, &c. When cold, they are more 
directly sedative, and are generally used to subdue inflamma- 
tion, or to overcome muscular action, or the tonic rigidity of 
tissues, as in the reduction of hernia. It must, however be 
borne in mind, that the effects of these applications vary 
much m different individuals ; thus in some, a warm poultice 
or fomentation, will resolve a phlegmon which presents, as 
nearly as can be judged, the same condition as one which, 
in other individuals, is most relieved by cold. The feelings 
of the particular patient should be consulted, to enable the 
surgeon to determine when one mode of treatment should be 
substituted for, or even be used instead of, the other. 

In enumerating the circumstances to which these dressings 
are particularly applicable, it is hardly necessary to remark 
that the substances with which they may be medicated will 
modify accordingly their general action. 

Within the last two or three years, an article of English 
manufacture, called. "Spongio-PUine," has been introduced 
o the notice of the Profession, and recommended by the sur- 
gical staffs of several of the London Hospitals. It is also 
used to^a considerable extent in the Massachusetts General 
iospitai, in Boston, and perhaps elsewhere in our own 
country. 



46 SURGICAL DRESSINGS. 

It is in sheets, three-fourths of an inch to an inch in thick- 
ness, looking very much like a smoothly-cut slice of sponge, 
one surface being covered with a sort of glazing of India- 
rubber. 

It imbibes water very freely, and the glazed surface pre- 
vents evaporation, as a piece of oiled-silk when laid upon a 
poultice. When wet it is not too heavy to be comfortable. 
The advantages claimed for it are its durability, its capability 
of being washed, and thus answering for different patients ; 
and its cheapness, as compared with the cost of the materials 
of which poultices are made, or of those used in the prepara- 
tion of fomentations ; it being remembered that the same 
piece of Spongio-Piline will last, as it is said, a very consi- 
derable time, and be serviceable to a number of patients. 
This last claimed advantage is, w T e think, of questionable 
reality ; for there would certainly be, to say the least, great 
probability that by thus preserving a piece of dressing as a 
sort of heir-loom, various inconveniences and dangers would 
arise from the transference from person to person of irritating, 
offensive, or inoculable matters. To furnish a piece of fresh 
" Spongio-Piline" to each hospital-patient w T ho required an 
emollient application, would be a very expensive charity. 
Having, by way of experiment, applied a piece of this article, 
saturated with w r arm water, to our own person, we confess 
that the effect was less agreeable than that produced by a 
well-made poultice or a fomentation. 

9. Lotions are composed of water variously medicated. 
They are usually applied upon some soft porous material, 
as lint or folded linen ; they may be used tepid or cold ; in the 
choice of temperature, the feelings of the patient may be very 
properly appealed to by the surgeon. If a refrigerant effect 
is desired from the wash, it should be applied upon a single 
fold of lint, or linen, and left exposed, or but slightly protected, 
so that evaporation may not be interfered with ; where such 
an action is not called for, several folds of the porous sub- 
stance should be laid upon the part and covered by a piece of 
thin oiled-silk — the whole to be retained in the manner alludec 
to with regard to the poultice. 

As a general rule, lotions should be employed preferably 
to cerates, as being more cleanly, and not liable to become 



SURGICAL DRESSINGS. 47 

irritating from high temperature of the part, or season of 
the year. 

Formulae for several lotions will be found at the end of the 
volume, with the uses of each. 

10. " Cerates are unctuous substances, consisting of oil 
or lard perfectly fresh and sweet, united with wax, sperma- 
ceti, or resin, to which various medicaments are frequently 
added. Their consistence, which is intermediate between that 
of ointments and of plasters, is such that they may be spread 
at ordinary temperatures upon linen or leather, by means of 
a spatula, and do not melt or run when applied to the skin." 
(U. S. Dispensat.) They are used as applications to abraded 
or ulcerated surfaces, and their composition is varied for 
adaptation to each case. 

11. " Ointments are fatty substances, of the consistence 
of butter, such that they may be readily applied to the skin 
by inunction. " (U. S. Disp.) They are simple, or com- 
posed of various medicaments. The ointments, as well as the 
cerates, are easily affected by a high temperature, becoming 
rancid and unfit for use. They are usually applied upon the 
sound skin. 

A number of ointments and cerates, such as have been 
found useful, are given at the end of the book, with their par- 
ticular applications. 

12. Liniments are intended for application to the unbroken 
surface, by friction with the hand, or soft flannel. Oil should 
constitute the basis of the liniment, and with it may be con- 
joined a variety of modifying ingredients, so that it may be 
rendered soothing, or irritating, as required. 

The reader will find formulae for the preparation of many 
very serviceable liniments, at the latter end of the volume. 

13. The Sponge, though it is not chiefly used as an article 
of dressing in surgery, is of such essential importance to the 
surgeon, that a few words concerning it will be proper. 

The common sponge, as found in the shops, is too full of 
gritty particles to be fit for surgical purposes. It may be 
sufficiently well prepared for ordinary uses, such as the 
cleansing of uninjured surfaces, by maceration in boiling 
water, and subsequent beating, until the sabulous or calcareous 
particles are generally removed. But for nice purposes, as 
the washing of inflamed or ulcerated surfaces, still farther 



48 SURGICAL DRESSINGS. 

preparation is requisite ; after having been treated as above, 
it should be macerated in water acidulated with about one- 
thirtieth of its bulk of chlorohydric acid ; dried and beaten 
again, and then bleached by exposure, when moist, to the 
vapour of chlorine, or some other decolorizing agent. It is 
now soft and clean. 

Bandages and the variety of apparatus employed in the 
treatment of surgical diseases and injuries, will be considered 
hereafter. 



CHAPTER III. 

GENERAL RULES FOR DRESSING. 

If a surgeon is called upon to attend to an injury just 
occurred, he should take a rapid, yet careful, observation of 
the patient, in order to ascertain the condition of his strength 
and mental functions, and to discover if there be any circum- 
stances calling for prompt attention previous to the systematic 
application of a dressing. Thus, if there be much prostra- 
tion present from any cause, fresh air and cold water should 
be freely employed to revive the patient ; or a little wine and 
water, with or without laudanum, should be administered ; 
and all obstacles to free respiration, such as a cravat, a tight 
vest, pressure around the abdomen from tight pantaloons, 
should be at once removed. If there be an external wound, 
it should be immediately examined, and prompt measures taken 
to arrest hemorrhage, if any exist. 

As soon as these preliminaries have been attended to, the 
surgeon may proceed to the regular application of the dress- 
ing, as in an ordinary case where no such emergencies present 
themselves. 

Having first arranged such articles of dressing as are 
likely to be needed in the case under consideration, and con- 
veniently disposed of the necessary instruments, (all useless 
display being avoided, as being not only uncalled for, but 
positively annoying to the patient,) — and having at command 
sponges and towels, and one or two basins of warm water, 
the surgeon should expose the diseased or injured part. In 
doing this, great care and the utmost gentleness should be 
observed ; if the patient be dressed, and the affected part, 
as, for example, the arm or leg, be very sensitive and painful, 
the clothes should be removed by ripping them along a seam, 
rather than be drawn off in the usual manner ; and any ap- 
plication which may have already been made must be with- 
drawn with the same care, so as not to inflict any unnecessary 
suffering. 

K (49) 



50 GENERAL RULES FOR DRESSING. 

The affected part and the surrounding surface should now 
be cleansed as perfectly as can be effected, without too much 
pain, by means of a sponge and castile-soap and water ; in ad- 
dition, if there be a wound, or if it be deemed advisable to ap- 
ply adhesive plaster, the surface should be denuded of hair, 
either by using a razor, or, which will answer equally well, a 
sharp scalpel. 

If there be hemorrhage to any notable amount, it should be 
arrested at once, by means of ligature or the application of 
cold, or some styptic ; or if it be very slight, a momentary ex- 
posure to the air may control it ; or, finally, the surgeon may 
trust for its arrest to the pressure of the dressing which he is 
about to apply. 

In the choice of the latter, the surgeon will, of course, con- 
sider the indication to be fulfilled in each particular case as 
of paramount importance ; but it should also be borne in mind 
that, lightness, freedom from any undue heating qualities, and 
cleanliness, are also essential to the perfection of a dressing. 
The retaining bandage should be such as may be applied and 
removed with as little difficulty and annoyance to the patient 
as is consistent with its special object, and all unnecessary 
pressure and envelopement are to be deprecated. 

After the dressing has thus been completed, the patient, or 
the particular part involved, must be placed in such a position 
as will most conduce to his comfort and security. Generally, 
a dependent position is to be avoided ; to prevent it, pillows 
may be placed beneath the limb, if the leg be involved, or, if 
it be the arm, a sling may be used to support it. 

The surface may be protected, 
Eig. 10. when necessary, from the pressure 

of the bedclothes, by placing over 
it an arch made of two semi-circles 
of hoop crossed upon each other, or 
of wires, or bamboo, fixed in 
frame (fig. 10). 

The dressing should be disturbed 
as little and as seldom as is consist- 
ent with the successful treatment of the case; all unnecessary 
renewals should be avoided. Generally, a dressing should 
not be renewed, or removed, so long as the first remains in 




GENERAL RULES FOR DRESSING. 51 

place, is clean, free from unpleasant smell, and is comfortably 
borne, and so long as no new and untoward symptom has 
occurred. 

All soiled dressings of every kind, the sponges, basins, and, 
in short, every thing which mars the cleanly appearance of the 
sick-room, or vitiates its atmosphere, should be removed as 
quickly as possible, and the bedding and clothing of the pa- 
tient be kept clean and well arranged. 



CHAPTER IV. 



ON THE USE OF WATER. 



The various modes in which water is made use of as a me- 
dicinal agent, by the surgeon in his daily duties, constitute a 
very important subject for study ; and one to which a few 
pages may profitably be devoted in a treatise on Minor Sur- 
gery. A brief consideration, therefore, will be here entered 
into of Irrigation ; the Douche ; the Water and the Vapour 
Baths, and finally the subject of Fumigations will be noticed. 
The best modes of insuring purity of the atmosphere of a sick- 
room, or of a hospital ward, will also be briefly alluded to. 



SECTION I. 

IRRIGATION. 

The surgeon has a very admirable substitute for the refri- 
gerant poultice in Irrigation, whereby the part may be kept 
constantly bathed in cold water of an uniform temperature. 
The water may be simple, or medicated by any of the sub- 
stances before enumerated, or others similar. The same plan 
might be used to insure a hot or warm fomentation, if the fluid 
could be maintained at one and the same temperature, but 
this would be attended with so much difficulty, that it would 
scarcely be prudent to attempt it ; since the alternate chilling 
and heating, to which the part would be exposed, from succes- 
sive changes in the thermometrical condition of the water, 
would be productive of serious inconveniences and dangers. 

The simplest method of effecting irrigation is, to cover the 
part with folds of soft linen, or lint, previously moistened, and 
to conduct a constant current of water to it through strips of 
linen, or cotton wick, from a reservoir, as, for example, a ba- 
sin placed at some convenient point. In order that the clothes 
of the patient, or his bedding, be not wetted, the part, — as a 

(52) 



IRRIGATION. 



53 



limb, — should be laid upon a pillow protected by a piece of 
oil-cloth so arranged as to form a sort of gutter, or funnel, 
along which the water may pass and fall into another reser- 
voir placed beneath it. M. Velpeau employs an apparatus, 
to fulfil the same purpose, which possesses this advantage, viz., 
that by it the amount of water and the force of the stream can 
be accurately regulated at pleasure, by turning a stop-cock. 
The annexed figure, (fig. 11,) taken from M. Velpeau's work, 




(Med. Operat. i. 265,) sufficiently explains the apparatus 
which he uses. 

The very great benefits derivable from the free and constant 
use of cold water in various surgical as well as medical dis- 
5* 



54 TIIE DOUCHE. 

eases, have been known for ages ; from time to time, however, 
it has been neglected, and again invoked : it is now, once more, 
resorted to, in the manner just described. It is particularly 
applicable to the early treatment of severe contused and lace- 
rated wounds ; sprains ; simple contusions ; dislocations, accom- 
panied by much pain after reduction, and many other painful 
injuries and diseases of the joints ; phlegmonous inflammation ; 
some varieties of painful ulcers, &c, &c. (MM. Velpeau, Be- 
rard, Malgaigne, South's Ed. Chelius, &c, &c.) The feelings 
of the patient should be consulted, in determining the propriety 
of continuing or relinquishing this plan of treatment. It 
should be discontinued, or at least suspended, if it increase the 
pain which it was intended to relieve, or induce sensations of 
chilliness and discomfort. 



SECTION II. 
THE DOUCHE. 

Another, and a very beneficial mode in which water, either 
warm or cold, may be applied to the surface of the body is, 
by the douche, which consists of a column of water varying 
in volume, made to fall upon the body from a greater or less 
elevation. Two series of phenomena attend the action of 
the douche: the immediate effect, or the shock, and that 
w r hich follows it, or the reaction. The intensity of these 
vary according to the temperature of the water, its volume, 
and the height from which it falls ; so that by regulating 
these circumstances, the peculiar effect to be derived from 
the douche, in each case, may be obtained. The primary, or 
direct result of the cold douche is sedative ; but, in ordinary 
cases, the nervous system more than recovers from its tem- 
porary depression, and an excitement ensues. This depres- 
sion may be prolonged, and the period of excitement post- 
poned, by gradually increasing the mass of water which falls 
upon the surface, or the force with which it descends, or the 
height of the column, or finally, by gradually lowering its 
temperature; and by combining all these modifications, a 
still greater effect will ensue. These circumstances should 
be attended to, therefore, where a sedative influence is re- 



THE DOUCHE. 55 

quired. So soon as a certain amount of depression occurs, 
the action of the douche may be suspended, and again re- 
sumed when reaction commences, as indicated by the return 
of the previous temperature, colour, and fulness of the part. 
This alternate action and suspension of the agent may be 
continued so long as may be indicated. After the douche, 
the surface should be gently dried by the application of a 
soft towel, so as not to excite a glow. After successive and 
repeated employment of the remedy, as above recommended, 
it will generally be found that reaction does not occur, or 
that it is very moderate and within bounds. 

The warm douche is productive of less depression, and the 
reaction is proportionally less in degree, than when the cold 
is resorted to. Generally, the warmer the water, other cir- 
cumstances being equal, the less the effects, both primary and 
secondary. 

To constitute the cold douche, the temperature of the water 
should be about 40° P., rarely lower ; that of the warm douche 
may very well be borne as high as 180° F. (Thomson, op. 
cit. 289.) The duration of their employment must vary very 
much ; in this respect the condition of each patient at the time 
must be the criterion. 

The water used for the douche is rarely medicated, except- 
ing by the addition of salt or of sea-water. 

The douche is especially applicable to cases in which it is 
desirable to invigorate the vital functions, generally, or to in- 
crease the tone of particular parts or organs. 

In cases of considerable general debility, the system may 
not be able to react sufficiently if the cold douche is employed 
at first ; here it is best to use the warm water, and gradually, 
on successive occasions, to lower the temperature of the douche, 
as the individual may have become stronger. When carefully 
employed in this way, it is one of the best general tonic reme- 
dies which can be made use of. 

In local paralysis its good effects are very manifest ; as, for 
instance, when directed upon the lower part of the spine, in 
cases of paralysis, partial or otherwise, of the sphincter mus- 
cle of the anus, or neck of the bladder ; in a similar condition 
of some of the voluntary muscles, as of the deltoid, resulting 
from an injury to the muscle itself, the douche should be di- 
rected upon the particular part. When the loss of power is 



i 



56 



THE DOUCHE. 



Fig. 12. 



more general, the effect of lesion of one of the central organs 
of the nervous system, it is advisable not to employ this re- 
medy until all the active symptoms of such lesion shall have 
been removed : such cases demand great watchfulness on the 
part of the surgeon. 

The simplest mode of applying the douche is to pour the 
■water from the nose of a teapot, or pitcher, from some conve- 
nient height ; if a large stream is desired, a basin or a bucket 
can be employed. The shower-bath is a common name for a 
variety of the douche. It is made in numerous ways. A very 
simple form, and one which is very convenient for surgical 
purposes, particularly in young patients, " consists of a hollow 
vessel made of tin, with a perforated bottom. The body of 
the vessel is of a bell-shape, with a hollow tube rising from the 
top, (b) and terminating in a broad perforated rim.(<?) When 
the bath is to be used, it must be sunk in a bucket of water, 
until it is completely submerged ; the air is thus driven out of 

the bath, which is filled with 
water. The thumb of an at- 
tendant is then to be placed 
upon the orifice in the centre 
of the rim, (c) and the bath 
raised from the bucket of wa- 
ter. The pressure of the air 
upon the holes in the bottom 
retains the water in the bath, 
and on raising the thumb from 
the upper orifice, the water is 
rapidly discharged. " (Fig. 12.) 
Portable shower-baths, holding 
from a quart to a gallon or 
more of water, are now made 
so that the patient may hold 
the vessel himself above his 
head, and discharge the water by raising a valve with his fin- 
ger. The shower bath may act on the whole surface, or upon 
a single part which is alone exposed. After its use, the body, 
or the parts which have been wet, should be thoroughly dried 
by friction with a towel, and the person covered as soon as 
possible. The best time for making use of the shower bath, 




BATHING. 57 

or the douche, if other circumstances will permit, is probably 
soon after rising in the morning. 






SECTION III. 
BATHING. 



Bathing forms a very important item in the treatment of 
many surgical diseases, so that a brief consideration of it will 
not be out of place here. 

Baths are of water, simple or medicated, and of vapour, — 
of water, or of some medicinal substance ; or, again, it may 
be a simple air-bath ; the latter is not much resorted to as a 
remedial agent. 

The water-baths are of most frequent use. For conve- 
nience-sake, they may be classed as the cold (temp. 33° to 
60° F.) ; the cool (60° to 75°) ; the temperate (75° to 85°) ; 
the warm (92° to 98°); and the hot (98° to 112°). (Forbes, 
art. " Bathing," in Cyclop. Pract. Med.) The thermometer, 
though answering very well as a general index of the tem- 
perature of the bath, is really a very arbitrary guide in pre- 
paring baths for particular individuals; since a degree of 
temperature which one person may consider "warm," or 
"temperate," may to another be disagreeably cold; the feel- 
ings of the patient, guided by the judgment of the attendant, 
constitute a much more rational and a safer guide. 

As in the case of the douche, two series of effects are ma- 
nifest when one takes a bath : the primary and the secondary. 
These vary in degree, with the temperature of the water. 
The greater the difference between the temperature of the 
bath and that of the body, the more marked will be the im- 
mediate effects, or the shock ; and these will be depressing, or 
stimulating, as the temperature of the water is below or 
above that of the surface, and proportionally so. A cool, 
and still more a cold, bath produces directly a sedative or 
depressing effect ; but in the course of a few minutes, unless 
the patient be very feeble indeed, the system recovers from 
this, and an excitement, proportioned to the previous de- 
pression, takes its place. This condition continues a longer 
or shorter time, and a second stage of depression ensues, 



58 BATHING. 

from which reaction does not occur, so long as the individual 
is exposed to the same temperature. After the patient is 
removed from the bath and properly attended to, the excite- 
ment continues for a time, and then gradually the system re- 
acquires its former standard, or retains permanently a mode- 
rate elevation. 

A hot bath produces immediately an excitement of the 
system, as indicated by fulness of the superficial vessels, 
flushing of the face, increased force and frequency of the 
heart's action, throbbing of the vessels of the head and neck ; 
the latter phenomena are sometimes so strongly manifest as 
to require the employment of cold applications to the head, 
and even the use of the lancet. Soon, however, either with 
or without the aids just mentioned, perspiration breaks out 
very freely upon the face, the excitement of the heart sub- 
sides, and the patient becomes more and more relaxed, and 
not unfrequently faints ; this condition of relaxation continues 
for a considerable time after the bathing has ceased. 

The warm bath generally produces a soothing, tranquil- 
lizing influence, allays restlessness, assuages pain, and often 
induces delightful sleep. The excitement which it causes is 
very moderate, and if used permanently, it may be considered 
an excellent tonic, as is the cool or cold bath, under proper 
regulations. 

Bathing is, therefore, applicable to a variety of surgical 
diseases. As a calmative agent, it is employed in numerous 
subacute inflammations, in many diseases of the skin, &c, &c. 
As a tonic, it is applicable to cases of generalor local debility ; 
as a stimulant, to the same sorts of complaints ; as a depress- 
ing remedy, it is often made use of to overcome violent pain, 
spasmodic muscular contraction, as in the reduction of dislo- 
cations, to allay spasm of the neck of the bladder, to aid in 
the return of a hernial protrusion, and the like. 

In giving a bath, the water should be preserved, as far as 
possible, at the same temperature throughout its use. When 
the bathing is completed, the individual should be carefully 
rubbed dry with towels, and protected from exposure to a 
current of air. 

Common sense will suggest at the time some apparatus 
suitable for the administration of this remedy; if possible, 
it should be large enough to contain the entire person, but in 



BATHING. 



59 



the absence of such a convenience, a common water-cask 
might be employed, or a washing-tub ;— care being observed, 
if the bath be warm, to protect, by a blanket, such portion 



Fig. 13. 




of the surface as may be uncovered by the water. Dr. 
Thomson (op. cit., p. 296) has contrived a very convenient 
apparatus for bathing ; he thus describes it : — " It consists 
of a hammock (a) of Macintosh's cloth, which is extended 
upon two long poles (6 5), passed through a broad seam on 
each side of the hammock, and kept asunder by the cross 
pieces (c c\ which are attached to the poles by the thumb- 
screws (d d d). At one end of the hammock is an air-pillow, 
which can be readily blown up ; and below it, is a flexible 
tube (/), made of the same material as the hammock, by 
which any water it may contain can be readily drawn off. 
"When the poles are fixed, as in the above figure, and the 
open end of the flexible tube is twisted around one of the 
thumb-screws, the bath is ready to receive the water. It may 
be supported upon two chairs, or upon folding tressels (e e). 
The advantage of this bath is, that it requires a very small 
quantity of water compared to that demanded for other 
baths ; that it requires no sheet for the bather to rest upon ; 
and, when the bathing is completed, the poles and the folding 
tressels can be placed aside in a small closet, or in the corner 
of a dressing-room, and the hammock, when dried, put into a 
drawer." This apparatus will be found very convenient on 
board ship, or in camp, where convenience in transportation 
and economy of space must be consulted. (Fig. 13.) 

Partial baths are very often used, and are of great service 
in many cases. Thus the pediluvium, or foot-bath, may be 
the means of effecting powerful and efficient derivation from 



60 



BATHING. 



Fig. 14. 



the head, and of inducing a considerable degree of relaxation 
of the whole frame. An ordinary bucket may be partially 
filled with water of as high a temperature as the patient Gan 
bear, rendered more powerful, if desired, by the addition of 
mustard-flour or cayenne pepper, or some liquid stimulant ; 
the patient may sit up in a chair, while the feet are in the 
water, or he may remain in bed, with his limbs projecting 
over its edge into the bucket which is supported upon a chair 
conveniently placed. He should be well wrapped up during 
the process ; from time to time, portions of water should be 
withdrawn from the bucket, and hot water added. The bath 
may be continued for fifteen or twenty minutes, or longer. 

The hip-bath furnishes a very conve- 
nient and powerful means of acting upon 
the lower part of the spinal marrow and 
the pelvic organs. It may be very well 
taken in a vessel, of which the annexed 
drawing illustrates the form ; it has the 
important advantage of well supporting 
the back, while the patient is in the sit- 
ting posture. (Fig. 14.) 

Baths are variously medicated to suit 
particular indications ; several of such 
modifications will be given at the end of the volume. 

The vapour bath may be made to answer many of the in- 
dications fulfilled by the water bath ; its general effects are 
very similar. The intensity of its action varies much, accord- 
ing as it is allowed to act upon the surface merely, or as it is 
inhaled also. Dr. Forbes, (art. "Bathing/' op. cit.) gives the 
following comparative statement, by which it is supposed that 
the vapour bath produces effects equal to 




The tepid bath, at 85°— 92°, its own temp, being 90°— 106°,' 90°— 100° 
" warm " 92°— 98°, " " 106°— 120°, 100°— 110° 

" hot " 98°— 106°, " " 120°— 160°, 110°— 130° 

Not breathed. Breathed. 



Their administration is very simple, and is attended with 
less inconvenience, oftentimes, than the use of the w r ater bath. 
The readiest mode of giving a vapour bath is to seat the pa- 
tient upon a chair, and at his feet place the vessel of water 
sufficiently heated ; surround the whole, — patient, chair, and 



FUMIGATIONS. 61 

water, — with a blanket, or a mantle of waxed or oiled cloth, 
or of India-rubber cloth, which may envelope the head, if it be 
considered advisable that the vapour be inhaled, or simply en- 
closing the neck, if otherwise; to keep the water at a proper 
temperature, a heated brick may be immersed in it, or the 
vessel placed upon it, from time to time, as required by the 
lowering temperature of the fluid. If the patient remain in 
bed, a flexible tube can be easily introduced beneath the bed- 
clothes, communicating with the interior of a vessel, as an or- 
dinary tea-kettle, in which vapour is being generated : or a 
plate containing the fluid and a hot brick may be placed in 
the bed, and an arched framework thrown over it to protect 
the bedclothes. 



SECTION IV. 
ON FUMIGATIONS. 

When solid substances are vaporized, and thus made to act 
upon the surface, as medicinal agents, the process is called 
Fumigation, and is effected by placing the substance to be 
used in contact with a body heated at a sufficient temperature, 
and so arranging the position of the patient as that the fumes 
may come in contact with his surface. The arrangements 
recommended above in the application of the vapour bath may 
be employed likewise in fumigating ; the same, or even greater, 
care being observed to protect the air-passages, if the fumes 
are irritating, or not intended to be inhaled : again, a large 
box, or a hogshead, may answer very well, being so contrived 
as that the head may be guarded against the vapour. 

The articles most frequently employed in fumigating the 
surface, or a particular part of it, — are sulphur, nitre, cinna- 
bar, arsenic, benzoic acid, chlorine gas, nitrous acid, &c, &c. 

Vapours, whether by the vapour bath, or by fumigation, are 
chiefly employed in affections of the skin, some forms of chro- 
nic rheumatism, periostitis, and the like. 



62 DISINFECTING AGENTS. 

SECTION V. 
ON DISINFECTING AGENTS. 

A pure atmosphere is one of the most important requisites 
in the treatment of disease, and it is one which, in surgical 
practice particularly, is difficult of acquisition oftentimes. It 
becomes necessary, therefore, that the surgeon should devote 
some attention to this matter. 

The method which suggests itself most naturally to the 
attendant is, to effect as perfect ventilation as circumstances 
will permit. For this purpose, some method should be 
adopted whereby the air in the patient's apartment shall be 
frequently renewed by the introduction of fresh air from 
without, displacing that within the room. When the tempe- 
rature is such as to admit of keeping a fire in the chamber, 
the vitiated atmosphere will ascend freely through the 
chimney, thus allowing pure air to take its place; but in 
warm weather this source of purification is cut off, and the 
surgeon is obliged to rely chiefly upon the windows and doors, 
as affording avenues through which an interchange may be 
effected of the air within and without. This mode of purifi- 
cation may be much aided by the use of various disinfecting 
agents, which neutralize, more or less, the exhalations and 
effluvia within the sick-room. Of these, the various sub- 
stances which contain chlorine are most in use. They pro- 
bably produce their effect by the liberation of chlorine gas, 
which combines with the offending gases. The chlorides of 
calcium and of sodium are the compounds generally employed 
as disinfectants ; they are used in a solid state, placed in 
different parts of the room, in some suitable dish, and kept 
moistened with water, or with dilute sulphuric acid, which is 
still better ; or they may be rendered liquid for application to 
the surface of the body and to the bedclothes of the patient. 
The liquid chloride of calcium may be prepared thus :- 
Introduce into a common glass retort fourteen parts of black 
oxide of manganese, six parts of chloride of sodium, the same 
proportion of sulphuric acid, and twelve parts of water. The 
chlorine gas will be evolved without the aid of heat applied, 



DISINFECTING AGENTS. 63 

and should be transmitted through a tube attached to the 
neck of the retort to the bottom of a vessel filled with a satu- 
rated solution of lime, until the evolution ceases. The water 
thus impregnated should be diluted with about forty parts of 
fresh water, for ordinary use. 

The liquid chloride of sodium is prepared in the same 
manner : a solution of one part of sub-carbonate of soda, in 
twenty parts of water, being substituted for the lime-water. 
The solution should be diluted with about thirty parts of 
water. These liquids are sprinkled upon the patient's clothes 
and bedding, and a portion may be added to the water used 
in washing any diseased part : for this latter purpose, the so- 
lution of the chloride of sodium is generally preferred, (Cyclop. 
Pract. Med.) 

Labarraque's solutions of these chlorides are now sold very 
generally throughout the country. 

A solution of the chloride of zinc is also employed as a cor- 
rector of the atmosphere. 

Chlorine gas may be very easily liberated from common 
salt, by pouring concentrated sulphuric acid upon it, in the 
proportion of one part of the acid to three parts of the 
salt. 

An objection to the use of the chlorides arises from the 
smell of the preparations themselves being disagreeable to 
many persons. 

Fumigations by nitrous acid vapour have been resorted to, 
and with much success. The vapour is obtained by the action 
of sulphuric acid on nitrate of potassa, in equal proportions, 
without the aid of heat ; care is necessary lest the fumes be 
disengaged too rapidly and too abundantly, and thus prove a 
source of irritation to the respiratory muscles. 

The common quicklime possesses the power of absorbing 
many of the gases on which the noisome atmosphere of the 
sick room depends. It is placed in plates, or other dishes, 
and set in various parts of the chamber. 

M. Le Doyen has recently recommended a disinfecting 
agent which seems to possess many advantages over the 
others, and a very important excellence of this preparation 
is, that it has no odour itself. It consists of a solution of 
the nitrate of lead, and can be prepared by dissolving litharge 



64 DISINFECTING AGENTS. 

in one part of nitric acid, mixed with about ten parts of 
water. It is used in the same way as the liquid chlorides. 

To insure any degree of purity of atmosphere, it is abso- 
lutely essential that the patient's apartment be kept clean, 
and that all useless clothing and furniture, which may attract 
offending gases, be removed. The dressings which have been 
changed, the water with which diseased parts have been 
cleansed, all vessels containing discharges from the patient, 
should be taken out of the room as soon as possible. Fre- 
quent white-washing of the walls and ceiling of the chamber 
will conduce very much to the preservation of a pure atmo- 
sphere, probably on account of the absorbing property of the 
lime over the effluvia. 

The most efficacious method for disinfecting substances, 
such as clothing, which retain infectious agents, is to expose 
them to an elevated temperature, as, for example, a tempera- 
ture of 200° or more, of Fahrenheit's scale; the heat may 
be employed dry, or in the form of steam. The action of 
heat is effectual in a very much shorter time than an ordinary 
current of air. 



PART II. 

ON BANDAGES AND THEIR APPLICATION. 
CHAPTER I. 

Bandages are employed in surgery to retain dressings 
upon the surface of the body, or other applications ; and also 
as a means of restoring and confining to their natural situa- 
tion parts which may have become displaced. 

The materials used for bandages are generally muslin, 
linen, flannel, or calico : sometimes gum-elastic cloth may be 
employed. Of these materials that which is most frequently 
selected is muslin, either bleached or unbleached ; it is cheap, 
and everywhere to be found. Flannel is, in some circum- 
stances, preferable to muslin, in consequence of its greater 
warmth and elasticity. 

Bandages are simple, as when formed from the roller ; or 
compound, when prepared from one or more pieces adapted 
by size and conformation to particular objects. 

We shall first describe the different bandages commonly 
employed, and then treat of their several uses, as applicable 
to the different regions of the body. 

SECTION I. 
THE ROLLER, OR SIMPLE BANDAGE. 

There are but very few of the ends ordinarily to be attained 
by bandaging, which may not be gained by a skilful dresser 
with the simple roller. 

It is prepared from any of the materials above-mentioned, 
but for general purposes muslin is selected. It should be 
torn or cut into strips, varying in length and width, accord- 
ing to the part to which it is to be applied, and rolled into 
6* (65) 



G6 



THE ROLLER, OR SIMPLE BANDAG: 



the form of a solid cylinder: this latter object maybe effectec 
by the hands alone, or by making use of a very simple ma 
chine contrived for the purpose. If rolled by the hands, th( 
strip should be folded at one extremity several times, until il 
shall have acquired a certain degree of solidity; then th( 
ends of this axis are held, and its mass made to revolve, be- 
tween the thumb and forefinger of the right hand, while th< 
free portion of the strip is pressed by the thumb and fore 
finger of the left hand, and allowed to pass from between them 
smoothly, and with some degree of tension, as the cylinder h 
gradually forming. 

Figure 15 presents a view of a machine for rolling the 
simple bandage : it sufficiently explains itself. 

Fig. 15. 




If but a single cylinder is formed, the roller is said to b( 
" single-headed ;" if there be a cylinder rolled at each extre- 
mity of the strip, it is called " double-headed," and the un- 
rolled portion between the two cylinders is termed the " body" 
of the roller. 

In applying this bandage, the external surface of the free 
extremity of the roller is laid upon the part, and retained 
there by the fingers of the left hand, until fixed by a few 
turns of the roller, the cylinder being held in the palm of the 
right hand by the thumb and fingers ; care is necessary thai 
the bandage be laid smoothly and evenly upon the surface, 
and that a uniform degree of pressure be exerted by each 
successive turn. After the rolling is completed, the free 



THE ROLLER, OR SIMPLE BANDAGE. 67 

extremity of the bandage is most easily confined by a pin 
inserted transversely, or if parallel with the length of the 
bandage, the pin should be introduced with its point towards 
the free end of the roller, otherwise it is liable to be drawn 
out by the constant strain of the bandage upon it. When 
the part to which the bandage has been applied is very small 
in circumference, and the bandage itself very narrow, the 
extremity of the latter may be conveniently attached by slit- 
ting it longitudinally through the middle, and tying the ends 
around the part ; as, for example, the finger or toe. 

Sometimes the roller may be wetted previous to its appli- 
cation, as, for instance, when it is used to confine the band 
to which the pulleys are attached, in the process for reducing 
a dislocation ; the band is thus more firmly secured than when 
a dry roller is employed. But in ordinary cases of bandaging, 
a wet roller should not be used, for as it dries, it shrinks and 
produces a much greater degree of pressure upon the soft 
parts than is consistent with safety. 

In some cases it may be advisable to saturate the bandage 
with starch, which, wiien it has become dry, forms a stiff, 
firm casement. A more particular mention of this, consti- 
tuting what is generally called "the immovable dressing," 
w r ill be made hereafter. 

The simple bandage receives different appellations ac- 
cording to the mode of its application, or the direction w T hich 
the roller is made to assume ; and again, with reference to 
the object to be accomplished by it. Under the first division 
we have the circular, the spiral, the crossed, the spica, and 
the recurrent bandages. The second division embraces the 
uniting, the dividing, the compressing, the expelling, and the 
retaining bandages. 

1. The circular is that of which the folds are horizontally 
disposed, or nearly so ; each successive fold almost completely 
overlapping that which preceded it. (Fig. 16, a.) 

2. The spiral ascends obliquely around parts more or less 
conical in form, each fold of the roller applying itself 
smoothly and flatly to the surface. Sometimes the edges of 
the roller overlap each other at each successive turn, when 
the bandage is termed by the French, u en doloires ; some- 
times a space intervenes between the folds, in which case it is 
termed "rampant:" fig. 16, c and b. If a limb, or any 



68 



THE ROLLER, OR SIMPLE BANDAGE. 



Fig. 16. 



other part of irregular form, is to be bandaged in its length, 
it will be impossible to cover its surface wholly, and at the 

same time to make equable 
pressure upon it at all points, 
by simple spiral turns : one 
of the edges of the roller 
will compress the surface 
more or less tightly, while the 
other will be loose. In order 
to obviate this difficulty it is 
necessary to reverse the turns 
of the roller, from time to 
time, as the varying form of 
the part may require : fig. 16, 
d. Some considerable prac- 
tice is needful to enable the 
dresser to make these reverse 
turns rapidly and neatly. 
The object is to reverse the 
relative positions of the edges 
and surfaces of the bandage, 
whereby its superior edge 
shall become the inferior, and 
the external face the internal. 
To accomplish this end properly, the spiral should be discon- 
tinued so soon as the bandage ceases to apply itself smoothly 
and flatly to the surface ; at this point two or more fingers 
of the left hand should be laid upon the roller at its superior 
edge, and the right hand, in which the cylinder is held as 
before directed, and which, until now, has been kept supine, 
should be pronated, while the body of the roller, thus re- 
versed, is suffered to apply itself, without traction, partly 
upon the preceding fold, and partly upon the surface which 
is to be covered ; then the cylinder is carried around to the 
opposite side of the limb, and the process just described re- 
peated. " The hand should press tightly upon each reverse 
to flatten and equalize it. (Fig. 17.) 

" Two precautions are to be observed in applying the re- 
versed bandage ; one is, not to unroll, in making the angle, 
more of the band than is absolutely necessary; the other, to 
carry the angles upwards in a perpendicular line, and always 




THE ROLLER, OR SIMPLE BANDAGE. 



69 



far from the part affected," in order that the increased thick- 
ness of the bandage at the angle or fold, shall not produce a 
corresponding pressure and indentation upon the diseased or 
injured surface. (Cutler, p. 25.) Each successive turn of 



Fig. 17. 




the roller should overlap from one-third to one-half of that 
which preceded it, the edges being made, as far as possible, 
parallel with each other. 

3. The crossed bandage is made by giving the turns of 
the roller the form of the figure 8, as is exemplified in the an- 
nexed drawing (fig. 18), in which the bandage is supposed to 
be applied to the bend of the arm after the operation of phle- 
botomy, to compress the incised vein. 

4. u When the turns of the roller cross each other in the 
form of the Greek lambda, and leave the band about one-third 
discovered, the a's being applied upon each other, the bandage 



70 



THE ROLLER, OR SIMPLE BANDAGE. 



Pig. 18. 




receives the name of spica ; fig. 16 e : it is said to be ascend- 
ant when the doloires are directed 
towards the superior part of the 
member, and descendant when they 
regard inferiorly." (Cutler, p. 25.) 
5. The recurrent bandage is 
applied to the head more frequently 
perhaps than to any other part. 
It derives its name from the fact 
that the roller, after covering a 
certain portion of the surface, is 
reflected in its course and brought 
back to its original point of depar- 
ture, at which it is again reversed 
towards the opposite point. This 
process is continued until the en- 
tire surface is covered ; each successive fold overlaying one- 
third, or more, of that which preceded it, and being confined 
at its point of reflection, temporarily by the fingers, -and per- 
manently by pins or by a circular turn of the roller, when the 
bandaging is completed. It forms an exceedingly neat and 
beautiful dressing. 

The same bandage is employed as an envelope to stumps, 
after amputation, for the purpose of retaining the other appli- 
cations which have been made. 

1. The uniting bandage, as it has its almost exclusive ap- 
plication to the treatment of wounds, will be considered when 
that class of affections is treated of. 

2. The dividing bandage is employed in the treatment of 
burns and granulating surfaces, where there has been much 
loss of substance, and where unsightly cicatrices are liable to 
be formed, and deformities from the approximation of opposed 
surfaces. The object of this bandage is, to obviate such ap- 
prehended difficulties by maintaining a proper separation of 
the parts : thus, for example, when the anterior face of the 
neck has been deeply injured by a burn, the lower jaw and the 
head should be prevented from being drawn towards the chest, 
as the ulcer cicatrizes, by means of a dividing bandage, hav- 
ing its point oVappui around the shoulders and in the axilla. 
It is generally formed of the simple roller. 

3. The compressing bandage, as may be inferred from its 



THE ROLLER, OR SIMPLE BANDAGE. 71 

name, is employed to exercise pressure upon a superficial, or 
a deep-seated, part. Sometimes the roller is used alone, some- 
times its action is assisted by a compress. 

4. The expelling bandage, like the one last mentioned, 
consists of a roller, generally applied over a compress. It is 
employed to facilitate the expulsion of fluids from morbid ca- 
vities and canals. 

5. The RETAINING bandage is used to confine dressings in 
place, as also parts of the body which, having become re- 
moved from their natural positions, are replaced. 

6. The knotted bandage is sometimes advantageously em- 
ployed to arrest bleeding, particularly of the temporal artery ; 
it will be described hereafter. 

The ability skilfully and neatly to apply and adjust the 
roller, is of very great importance to the surgeon; and the 
time which the young dresser devotes to its acquisition is well 
spent. It can only be gained by frequent practice ; verbal 
descriptions, and the best executed illustrations, should be con- 
sidered merely as guides and aids ; they cannot impart prac- 
tical skill, any more than the perusal of volumes on anatomy, 
to the exclusion of dissections, can render the student ac- 
quainted with the mysterious construction of his material 
frame. Let each one, therefore, spend a few leisure moments 
every day, with some companion, in the practical application 
of the roller : at first, reference to some book on bandaging 
will be necessary, but after a certain degree of skill has been 
icquired, the volume may be laid aside ; the student's good 
sense, and the familiarity which he has already gained with 
the mode of bandaging, combined with his knowledge of the 
particular object to be attained in each case, will be his best 
guides and his best adviser. The more skilful he becomes in 
the management of the roller, the more entirely will he be 
able to dispense with compound and complicated bandages ; 
the more capable will he be to accomplish all that he desires 
by this simple means. 



i 



72 COMPOUND BANDAGES. 

SECTION II. 
COMPOUND BANDAGES. 

These are intended to fulfil some especial indication, which 
owing, it may be, to the peculiar conformation of the part or 
parts involved, cannot be so well attained by the simple roller. 
They are formed of one piece, or many pieces, of muslin, or 
of some other material, to which are given a shape and con- 
formation varying according to the judgment of the dresser. 
There are some bandages, however, so commonly made use of, 
that they require particular description. Such are the cru- 
cial, or, as it is generally called, the T bandage ; the invagi- 
nated ; the many-tailed, or the split ; the laced ; the sheath, 
and the suspensory bandages. 

1. The T bandage derives its name from its shape. It con- 
sists of a horizontal band to which is attached another at about 
its middle, having a vertical direction, perpendicular to the 
first ; when there are two vertical bands, it forms the double 
T bandage. The length and breadth of the strips vary with 
the dimensions of the part of the body to which the bandage 
is to be applied, and the particular end which it is expected 
to secure. Sometimes, as for example, when it is employed 
to retain dressings upon the hand, one of the bands is perfo- 
rated to admit of the insertion of the fingers. 

2. The invaginated bandage is used to approximate the 
edges of wounds, or fragments of bone, as in fracture of the 
patella. It is made in two different ways, according to the 
indication to be fulfilled by it. Thus, if the object be to draw 
together the lips of a longitudinal wound of a limb, a roller 
should be selected corresponding in width to the length of the 
wound, and long enough to be passed several times around the 
limb. At its free extremity it should be slit into two or more 
tails of a convenient length, and corresponding fenestra be 
made in the band at a distance from the end rather greater 
than the circumference of the limb. In its application, the 
undivided portion of the band should be placed opposite to the 
wound, and the tails passed through the fenestra, thus sur- 
rounding the limb ; then, with a compress placed near each lip 



COMPOUND BANDAGES. 73 

of the wound, its edges should be gently but accurately ap- 
proximated, and retained in apposition by several turns of the 
roller. For an illustration of this, see the Chapter on 
Wounds. 

The invaginated bandage for transverse wounds, fracture 
of the patella, &c, is made upon the same principle precisely ; 
it consists of two bands of convenient length and width, and 
of two rollers. Slits, as in the other bandage, are made at 
one end of one of the bands, and corresponding fenestras near 
one extremity of the other ; then, by means of the rollers, 
firmly attach the bands to the limb, the one above and the 
other below the wound, or the point of fracture, and having 
passed the tails of one through the fenestra of the other, draw 
the divided parts together, and confine them in this position 
by successive turns of the roller. If necessary, compresses 
may be used, as in the other case. 

3. The split or tailed bandage consists of a piece of 
muslin, or of some other fabric, divided at its extremities into 
a convenient number of tails, leaving the central portion of 
the band entire. Or a piece of muslin of the proper dimen- 
sions may be selected, to each extremity of which bands of 
suitable length and width shall be attached. Constructed 
after either method, this bandage is very useful and conve- 
nient in confining dressings. 

A very elegant modification of this bandage consists of a 
number of strips, varying in width from two to four inches, 
generally, and sufficiently long to extend about once and a 
half around the affected part, as the leg : these strips are so 
placed upon each other, successively, that each has about 
one-third of its width covered by that which succeeds it in the 
order of super-position, commencing from above. The strips, 
so arranged, may be attached in mass along the centre, by 
Imeans of a needle and thread, thus constituting the bandage 
of Pott, or they may remain unconnected, forming the band- 
lage of Scultetus ; the last possesses this great advantage over 
Ithe other, that any strip, or strips, which may have become 
boiled, can readily be withdrawn without deranging or removing 
the others, by simply pinning the fresh band to the extremity 
)f that which is to be rejected, and drawing it to the situation 
>ccupied by the latter in the bandage. 

These divided bandages form very light retaining and com- 
7 



74 COMPOUND BANDAGES. 

pressing dressings, and present an exceedingly neat and ele- 
gant appearance, when carefully adjusted. That of Scultetus 
is the one most frequently used. 

4. The laced bandage is made of some more or less elastic 
material, as buckskin, flannel, or caoutchouc, so shaped as to 
correspond accurately to the contour of the part to which it 
is to be addressed, and retained in situ by means of straps 
and buckles, or cords passed through a series of eyelet-holes, 
ranged along the edge of each flap. 

The laced bandage may be advantageously applied to any 
part of the surface, upon which a constant and equable 
pressure will be useful; its most frequent employment, how- 
ever, is around the joints, in some chronic affections, and on 
the leg in case of varicose veins. 

A very good substitute, in many instances, for the true 
laced or buckled bandage will be found in a knit woollen band 
of suitable width, having its two extremities firmly sewed to- 
gether, thus forming a circlet somewhat less in circumference 
than that of the affected part, and capable, thereby, of im- 
parting firm and elastic pressure around it. Or a similarly 
shaped band of gum elastic cloth may be used, with care to 
protect the skin from its irritating effects by lining it with 
linen, or by inserting a piece of linen, or silk, between the 
skin and the band. 

5. The sheath comes to hand already prepared for use, in 
the fingers of a glove ; or when a larger envelope is needed, it 
may be easily made after this pattern, of any suitable mate- 
rial. It is serviceable as a means of retaining applications 
upon the fingers, toes, or penis, and will be found to be much 
better adapted to this purpose than a narrow roller, which 
cannot be very neatly and conveniently arranged upon these 
parts, owing to their situation and size. 

6. The suspensory bandage is intended to afford support 
and protection to particular parts, as the nose, penis, or scro- 
tum. In its simplest forms its preparation is easy, being made 
of a piece of muslin or linen of convenient shape and dimen- 
sions, and having bands or pieces of tape attached to it, for 
the purpose of retaining it in position. In the stores in which 
surgical apparatus is sold, suspensory bandages for the scrotur 
will be found very elegantly made of network. 



mayor's system of bandaging. 75 

section iii. 

M. mayor's system of bandaging. 

Struck with the little change and improvement effected du- 
ring the preceding half-century, in that branch of surgery 
which is the subject of this volume, and aware of the difficulty 
often experienced, in some situations and circumstances, in se- 
curing a constant supply of the materials ordinarily employed 
in surgical dressings, M. Mayor, Chief-Surgeon to the Hospi- 
tal of Lausanne, Switzerland, has originated and developed a 
new system of bandaging. In the year 1832, he published a 
treatise on this subject, entitled, " Nouveau Systeme de Deli- 
gation Chirurgicale," which has now passed through three edi- 
tions. The object which M. Mayor had in view in his inves- 
tigations was, " To discover some simple means, easy of appli- 
cation, always at hand, or readily procurable, and well adapted 
to serve as a substitute for charpie, compresses, cushions, 
bands, bandages, and ligatures, which surgery requires for all 
sorts of dressings." His researches and practical experience 
have at length led him to the conclusion, that he has succeeded 
"in reducing, as far as is practicable, all kinds of apparatus 
to their simplest form, by associating them under one common 
principle ; so that the different parts of such apparatus, and 
the materials for all dressings, will be found to be so common 
and of such nature, that they may be always, or nearly always, 
at the disposition of the surgeon, and of all other persons, and 
in the absence of the practitioner, may be readily applied, 
after some little instruction, by the first comer." (Op. cit. 3d 
ed. p. 16 of the Introduction.) 

The whole ' materiel' of M. Mayor's system of bandaging 

may be reduced to a single square piece of muslin, or other 

suitable fabric ; or, in the absence of this, an ordinary pocket 

handkerchief, or a square cravat. From this primary form he 

makes four others, which constitute his whole array of ban- 

Idages ; these are the oblong band, made by folding the square 

[several times, until the desired width be attained ; the trian- 

Igular, formed by folding the square diagonally ; the cravat, 

Iprepared from the triangle, as the cravat for ordinary wear is 



76 MAYORS SYSTEM OF BANDAGING. 

made ; and the cord, which is merely the cravat rolled into the 
form indicated by the name. With these simple forms of ban- 
dage, M. Mayor proposes to replace all the ordinary bands 
and bandages of surgery. He contends that all or nearly all 
the indications which can be fulfilled by the latter, are equally 
well attained by the former, while these are always at hand 
in town and in the country, at sea or on land, in civil and in 
military practice. 

The above is a mere sketch, an outline, of M. Mayor's 
plan. For a detailed account of it, and for its adaptations 
to particular cases, the reader is referred to the treatise it- 
self. The system is very simple, and its applications may be 
acquired without difficulty. Where the object is merely to 
confine dressings, or to protect parts of the surface, or to 
support a limb, the simple means recommended and employed 
by M. Mayor will probably be found perfectly efficacious; 
but in the treatment of fractures, and in cases requiring 
well-regulated and firm compression, the author is inclined to 
think that they cannot be advantageously substituted for the 
roller and other bandages, ordinarily employed, excepting as 
temporary means, or in the absence of the others. In justice 
to M. Mayor, it must be observed, that he himself admits 
that there are some circumstances in which his own system 
of bandaging will be found less serviceable than the other. 

In the different sections on regional bandaging, the author 
will give such of M. Mayor's dressings as seem to him to be 
most worthy of attention. As an admitted system for prac- 
tical adaptation, it is not, according to the most accurate 
information which the author has been able to obtain, em- 
ployed in any country ; he deems it, therefore, superfluous to 
give its details. 



CHAPTER II. 

REGIONAL BANDAGING. 

SECTION I. 
BANDAGES FOR THE HEAD AND NECK. 

1. The recurrent bandage of the head is composed of a. 
single-headed roller about five yards long and two inches 
wide. 

Application. — The initial extremity of the roller is placed 
upon the lower part of the forehead, or on the temple, or 
occiput, and confined by a few turns circling around the head 
in a line running from just above the eyebrows to a point 
a little below the occipital protuberance : at the middle of 
this line, as at the forehead, the course of the bandage is 
reversed, and the reversed turn held by a finger of the left 
hand, while the cylinder of the roller is carried over the top 
of the head along the sagittal suture, to meet the circular 
turns at the occiput ; here a reverse is made again, and con- 
fined by an assistant, while the cylinder returns in an ellip- 
tical course to the forehead, w T here it is retained upon the 
first reverse by the finger of the dresser. In this manner 
successive reverses are made at the forehead and occiput, and 
repeated returns of the roller to and from these points in 
elliptical folds, each successive fold overlapping about one- 
third of the preceding, until at length the side of the head 
is completely covered. The other side is covered in the same 
manner by successive folds similarly overlaying each other, 
and the bandage completed by circular turns firmly applied 
over the common points of reverse, in front and behind : to 
render the dressing still more secure, a single turn of the 
roller, commencing at the middle of the last circular, laterally, 
may be passed beneath the jaw, to terminate at the corre- 
sponding point of the circular on the opposite side. Pins 
7 * (77) 



78 BANDAGES FOR THE HEAD AND NECK. 




Fig. 19. should be inserted in the 

bandage to confine the 
reversed turns, at the 
forehead and occiput, 
and one also at the ex- 
tremity of the roller. 
(Fig. 19.) 

Use.— To retain dress- 
ings upon the scalp, and 
to exercise moderate 
pressure where such may 
be required. 

2. The T bandage of 
the head is composed of 
a band two yards long 
and two inches wide, to 
which is attached, at right 
angles, another strip of 
the same width and half a yard in length. The longer band 
is then rolled into two cylinders. 

Application. — The dresser, taking his station in front of 
the patient, applies the bandelette to the top of the head, 
over which it passes to the nape of the neck, while the 
longer portion of the bandage starting from the middle of the 
forehead, circles around the base of the cranium, on each 
side, to the occiput, where, just beneath the occipital protu- 
berance, it meets the vertical portion ; the latter having been 
crossed and confined in this position by the other division of 
the bandage, is reflected over the vertex to the forehead, 
where it is retained by the folds of the longer band which 
expends itself in circular turns. 

A double T bandage may be used instead of the single, if 
more convenient ; in either case, the course of the limbs of 
the bandage may be more or less varied to suit particular 
purposes. 

Use. — To retain dressings upon the scalp. 
3. The four-tailed bandage of the head is formed of a piece 
of muslin one yard long and six inches wide, split at each 
extremity to within about three inches of the centre. 

Its application may be varied according to the part of the 
head upon which it is intended particularly to act. 



BANDAGES FOR THE HEAD AND NECK. 



79 



Fig. 20. 




"When the wound is on the forehead, the unsplit portion 
is applied there, and the two upper tails, carried posteriorly, 
are fixed at the back of the head; 
the lower tails are then fastened 
either upon the vertex or beneath 
the chin, as the surgeon may con- 
sider it most convenient. 

" To confine a dressing upon 
the summit of the head, the poste- 
rior tails, (#, fig. 20,) are brought 
down and secured beneath the 
chin ; the anterior tails (5, b y ) after 
being carried to the nape of the 
neck and crossed, are fixed before 
the throat. 

" In applying it to the nape of 
the neck, the upper tails are con- ' 

ducted over the forehead, from whence, after being made to 
cross each other, they are returned, and fastened at the occi- 
put ; the lower tails pass round the neck." (Cutler.) 

Use. — As the last. 

4. The six-tailed, or the bandage of Galen,, consists of a 
piece of muslin a yard long, and a quarter of a yard wide, 
split at each extremity, to within three inches of the middle, 
into three portions, of which the central is rather the 
widest. 

Application. — Place the unsplit portion, a, of the bandage 
upon the top of the head ; then folding the edges of the cen- 
tral, bj tails inwards, so as to give them a triangular form, 
the base of the triangle being at the top of the head, draw 
the tails down over the ears and tie their extremities beneath 
the chin. Reverse the relative position of the anterior and 
posterior tails, bringing the latter, c, to the front, where they 
shall cross each other upon the forehead, and be confined : 
while the anterior tails, (i, are drawn round to the occiput, 
are crossed beneath the protuberance, and retained, as on the 
forehead, by pins. (Fig. 21.) 

Use, as the preceding, over which it possesses a supe- 
riority in being more secure, and in covering a large surface 
of dressing. 

5. The fronto-occipital triangle of Mayor, serves very well 



80 BANDAGES FOR THE HEAD AND NECK. 

the purpose of a retaining bandage. Its application is very- 
simple : place the centre of the base of a triangle upon the 

Fig. 21. 




forehead, just above the superciliary ridges, while the body 
of the triangle covers the top of the head, the apex hanging 
down upon the back of the neck ; draw the tails around the 
base of the cranium to the occiput, cross them beneath the 
protuberance, and then continue them respectively to the 
temples, or forehead, and confine their extremities by pins. 
The apex of the triangle, overlapped at the occiput by the 
tails, is reflected upon the latter, and, being continued up- 
wards upon the body, is pinned. 

The occipitofrontal and the bi-temporal triangles are ap- 
plied in the same manner as the last, excepting that in one 
case the base of the triangle is laid upon one of the temporal 
regions, and in the other upon the occiput. 

Uses, the same as of the bandage of four tails, &c. They 
are much more simple in their application than those hereto- 
fore described, and may very well supersede them. 

6. The knotted bandage is composed of a double-headed 
roller four yards long and two inches wide, and of a graduated 
compress. 



BANDAGES FOR THE HEAD AND NECK. 



81 



Application. — Place the compress over the wounded 
artery, and apply upon it the body of the roller ; then con- 
duct the heads around the cranium, one over the brow, and 
the other over the occiput, to cross each other at the opposite 
temple, whence they are returned to the compress ; on reach- 
ing this point they are twisted upon each other, and their 
courses changed, one mounting over the top of the head, the 
other descending beneath the chin, and both made to cross 
again at the opposite temple, after which the same route is 
continued to the compress, where a second twist is effected, 
and the course of the roller changed to the horizontal direc- 
tion, as at first ; again the heads cross each other upon the 
temple of the sound side, the compress is again reached, and 
a third twist made, after which the vertical course of the 
roller is resumed, and the bandage completed by a few cir- 
cular turns. 

Use. — To arrest hemorrhage from the temporal artery. 
This somewhat complicated bandage may be very properly 
superseded by a simple roller, and a compress which shall be 
retained and pressed upon the bleeding vessel by a few cir- 
cular turns. 

7. The four-tailed bandage of the chin is composed of a 
strip of muslin a yard long and three inches wide, and split 
longitudinally from each extremity, so as to leave but three 
inches of the central portion of the band undivided. 

Application. — Place the middle of the band upon the 
chin, and carry the two upper tails, a, a, 
along the base of the lower jaw around 
to the nape of the neck, where they are 
crossed, and afterwards conducted along 
the base of the cranium to the forehead, 
and there secured. The lower tails, 5, 5, 
ascend over the base of the jaw and the 
sides of the face, in front of the ears, to 
the top of the head ; here they cross each 
other and then descend, each on its re- 
spective side, to the base of the jaw, and 
are confined beneath the chin, (fig. 22). 

To increase the pressure exercised by 
this bandage, a compress may be applied upon any desired 
point. 



Fig. 22. 




82 BANDAGES FOE THE HEAD AND NECK. 



Use. — To retain dressings upon the chin ; it is also used in 
fractures of the lower jaw, and in dislocations of its condyles 
after reduction. For the same purposes the bandages for 
fracture of the lower jaw, invented by Drs. Barton and 
Gibson, of this city, may also be applied. (See Fractures of 
Lower Jaw.) 

8. The T bandage of the ear is formed of a horizontal 
limb two yards long and two inches wide, and of a vertical 
strip of the same width and half a yard in length. 

Application. — Place the vertical limb upon the ear, and 
exhaust the horizontal band in circular turns around the base 
of the cranium, passing just above the ear and over the fore- 
head and occiput ; then conduct the vertical limb beneath the 
jaw, up over the opposite side of the face and the top of the 
head to the point whence it started, and confine its extremity 
to the horizontal band. 

Use. — To serve as a means of retaining dressings upon 
the ear. 

9. The double T bandage of the nose is composed of a 
band one yard long and half an inch wide, upon the middle 
of which are attached at moderately acute angles, and at the 
distance of one inch from each other, two other strips half a 
yard long and of the same width as the first. 

Application. — The middle of the horizontal band is placed 
upon the upper lip, and its extremities 
are conducted below the lobe of the ear 
on each side to the nape of the neck, 
where they are tied in a bow-knot. 
The other strips are then carried 
obliquely upwards over the top of 
the head, crossing each other at the 
root of the nose ; having reached the 
occiput, they are inserted beneath 
the horizontal band, over which they 
are reverted upon the back of the 
head and confined, (fig. 23). 

Use. — To retain dressings upon 
the nose. 

10. The sheath of the nose is thus prepared : "A piece of 
linen is cut into a triangular form, of a sufficient size to cover 
the nose, with two holes perforated near the inferior angles 



Fig. 23. 




BANDAGES FOR THE HEAD AND NECK. 83 

to correspond with the nostrils ; a triangular portion is cut 
out from the superior angle of this, the apex of which looks 
downwards upon the median line of the nose, and the divided 
edges are sewed together ; thus a sort of bag is formed, 
capable of exactly lodging the nose. To the lower part of 
the bag is stitched a narrow band, half a yard long and half 
an inch wide, and to the summit a second band of like 
dimensions. 

"Application. — The bag is applied upon the nose; the 
surgeon lays hold of the inferior tails, and, passing them be- 
neath the ears, ties them in a bow upon the nape of the neck ; 
he then conducts the superior tail along the sagittal suture 
as far as the transverse band, under which he passes it, 
reflecting the end upwards to secure it upon the descending 
portion." 

Use. — The same as of the foregoing. (Cutler, p. 61.) 

11. A simple bandage for both eyes may consist of a strip 
of muslin two inches wide, and three feet long, of which the 
central part is placed upon the eyes, and the extremities tied 
upon the occiput. 

Use. — To retain dressings upon the eyes. 

If the object be merely to protect the eyes from the light, 
without exercising any compression upon them, it may be 
very conveniently attained by attaching to each side of a 
piece of muslin, or of green silk, of sufficient length and 
width to cover the eyes, a piece of tape, and then tying the 
two upon the occiput. Or the silk, or muslin, may be in- 
serted beneath the lower edge of a strip which passes just 
above the superciliary ridges, around the base of the cranium 
to the occiput, where its extremities are tied. By this latter 
arrangement cold or warm lotions may be applied to the eyes, 
or to one eye only, simply by saturating the pendulous flap, 
made in this case of linen. 

12. The monocle, or bandage for one eye, consists of a sin- 
gle-headed roller four yards long and two inches wide. 

Application. — Two circular turns are made around the 
head, crossing the forehead and occiput, after which the course 
of the roller is somewhat depressed, traversing the nape of the 
neck and passing beneath the ear of the affected side, to as- 
cend obliquely towards the affected eye, which it crosses dia- 
gonally ; continuing the same direction, it mounts over the fore- 



84 BANDAGES FOR THE HEAD AND NECK. 



Fig. 24. 




head and side of the head, crossing the top of the parietal su- 
ture, to descend again to the nape of the 
neck, from which point it renews its course, 
as just described. Two or three succes- 
sive turns are thus made obliquely around 
the head, in the form of doloires present- 
ing inferiorly, a, a, a ; and the bandage is 
then terminated by circular sweeps around 
the forehead and occiput, 5, 5, (fig. 24.) 

Use. — To confine dressings upon the 
eye. 

13. The invaginated bandage for the 
lip consists of a double-headed roller, from 
two to three yards long, and three- 
fourths of an inch wide, and of two small 
compresses. 

Application. — Place the body of the roller upon the fore- 
head, and conduct the heads, on each side respectively, around 
the cranium to the nape of the neck ; cross them at this point, 
and then carry them beneath the ears to the upper lip, over 
the compresses previously placed near to, and parallel with, 
the edges of the wound ; make a longitudinal slit in one of the 
tails, opposite the centre 'of the lip, and through it pass the 
other head; make, very gently and gradually, a sufficient 

strain upon the heads of the 
roller, and conduct them again 
to the nape of the neck, and 
thence to the forehead ; repeat 
this process until the requisite 
support is acquired for the lip, 
and then confine the extremities 
of the roller, in the customary 
manner, (fig. 25). 

Use. — To approximate the 
edges of transverse wounds of 
the lip, and to give support, also, 
to the hare-lip suture, or to re- 
place it after the withdrawal of 
the pins. 

14. A sheath for the tongue has been contrived by Pibrac, 
to serve as a means of confining it, in some measure, when 



Fig. 25. 




BANDAGES FOR THE HEAD AND NECK. 



85 



Fig. 26. 



wounded. It consists " of a little purse, a, for enclosing the 
point of the tongue, having at- 
tached to its base two silver 
wires, which are to be bent un- 
derneath the chin ; to this frame 
two ribbons are appended, which 
pass from the chin backwards, 
beneath the ears, to the nape of 
the neck, and thence ascend to 
be tied across the forehead. ,, 
(Velpeau, op. cit., vol. i. p. 198.) 
-(Fig. 26.) 

15. The mask for the face is 
made of a piece of muslin, or 
linen, as large as the face itself, 
having apertures cut in it to cor- 
respond with the eyes, nostrils, 
and mouth, and a strip of mus- 
lin attached to each angle. 

Application. — Place the 
mask upon the face so that the 
apertures shall be accurately 
adapted to the parts for which they were intended ; carry the 
superior strips along the base of the cranium to the nape of 
the neck, cross them there, then conduct them round to the 
chin and tie them upon the mask ; cross the inferior bands 
also upon the nape of the neck and terminate the bandage by 
knotting them upon the forehead. 

Use. — To serve as a simple covering to the face, and to 
confine dressings upon it. 

16. The cervical cravat of Mayor consists simply of a tri- 
angular piece of muslin, or an ordinary handkerchief, folded 
to the form of a cravat. 

Application. — Place the centre of the cravat opposite the 
larynx, the side of the neck, or the back of the neck, as may 
be most proper, and tie its extremities at the opposite point. 
Use. — To retain dressings. 

A simple piece of muslin or flannel is often used as a re- 
taining band, in this region. The objection to such an appli- 
cation, as commonly prepared, is that it soon becomes rolled, 
and ceases to cover the part properly. This difficulty may be 




86 



BANDAGES FOR THE HEAD AND NECK. 



Fig. 27. 



obviated by a simple method : take a piece of flannel or mus- 
lin, rather longer than the circumference of the neck, and 
wide enough to cover it completely ; fold it upon itself in its 
length, and cut from its anterior border, while folded, a trian- 
gular piece, of which the base presents upwards ; then sew the 
cut edges together, and unfold the band, which has thus ac- 
quired the form of a common stock, and will not become corded 
when worn upon the neck. Its extremities should overlap 
each other, and be confined by pins, posteriorly. 

17. The flexor bandage of the neck, which appears to be 

the most secure, and at the same time the most simple and 

convenient, is the one described by Velpeau, (op. cit. p. 203). 

It consists of a strong muslin cap for the head ; a band of 

stout material, three or four 
inches wide and about three- 
fourths of a yard long ; a roller 
two yards in length, and a circu- 
lar bandage for the chest, (to be 
described in the next section,) 
with shoulder and pelvic strips 
attached. 

Its mode of application varies 
somewhat with the indication it 
is intended to fulfil. 

If it be employed in the treat- 
ment of a transverse wound of 
the neck, for instance, it is thus 
applied : Fix the cap firmly to 
the head by means of a band 
passing under the chin ; place 
the undivided portion of the 
strong band above-mentioned 
upon the top of the head, its ex- 
tremity reposing upon the occi- 
put, while the split portion of the 
same band hangs down over th 
face upon the chest ; secure 
firmly upon the head, in this po 
sition, by several circular turn 
of the roller, and then, having 
flexed the head to the requisit 







BANDAGES FOR THE HEAD AND NECK. 



87 



degree upon the anterior face of the neck, pin the tails of the 
band, at a convenient distance from each other, to the tho- 
racic bandage which has been previously applied to the 
chest. 

The same may be used as a dividing bandage by simply 
reversing the relative positions of the extremities of the band, 
the undivided end being placed upon the forehead, and the 
split portion hanging down over the occiput, so that the head 
may be flexed backwards on the neck, or maintained upright, 
and so retained by confining the tails of the band upon the 
posterior aspect of the thoracic bandage. Thus applied, it 
will be of advantage in the treatment of burns, &c., &c, upon 
the front of the neck. 

Again, a lateral flexion maybe given to the head, as is seen 
in the annexed figure, (fig. 27). 

18. Professor Jorg's apparatus for the treatment of " wry- 
neck" consists of a pair of leather stays for the chest, and of 
a band or strong circlet for the head. On the centre of the 

Fig. 28. 




88 BANDAGES FOR THE TRUNK. 

stays, in front, is a ratchet-wheel, having the edge serrated in 
such a way as that it revolves only in one direction upon its 
axis, the reverse motion being prevented by a spring pressing 
against the teeth ; a band passes upwards from the wheel to 
be attached to the fillet opposite the side of the head ; then 
by turning the wheel by means of a key, a, the side of the 
head is approximated to the sternum, so as to counteract 
or overcome the opposing muscles of the affected side, 
(fig. 28). 

This instrument may be employed in those cases of torti- 
collis in which a considerable degree of force has to be exerted 
and continued for a length of time ; where less power is requi- 
site, the simpler bandage last-mentioned may be used. 



SECTION II. 
BANDAGES E0R THE TRUNK. 

1. The dorso-thoracic triangle. (Mayor.) 
Application. — Place the base of the triangle upon the 

anterior, or the posterior, aspect of the chest, as the seat of 
the injury may require, and tie the tails upon the thorax either 
before or behind, while the apex is allowed to repose over one 
of the shoulders, being attached to the base of the triangle 
through the intermedium of a band, if it be not sufficiently 
long of itself to reach this point. 

Use. — To retain dressings upon the anterior or posterior 
face of the chest. 

2. Circular bandage with straps, for the thorax. 
Composition. — A strong towel, or an oblong piece of 

muslin, folded upon itself to acquire sufficient strength ; and a 
band two feet long and four inches wide, split from one end 
through almost its entire length. 

Application. — The napkin is wrapped around the chest, 
its extremities overlapping and pinned; the undivided ex- 
tremity of the band is then attached in the same manner to 
the middle of this posteriorly, and its tails brought to the 
front, one over each shoulder, and pinned likewise to the 
same. 

Instead of the split band, a triangular piece of muslin may 



BANDAGES FOR THE TRUNK. 



89 



be used for the scapulary, by applying its base to the back 
of the neck, and attaching the apex to the thoracic bandage 
posteriorly, while the tails cross, one over each shoulder, to 
be pinned to the bandage in front. 

Again, the thoracic band itself may be rendered more effi- 
cient, if a constant compression be desirable, by substituting 
straps and buckles, or by lacing it, instead of securing it by 
means of pins. 

Use. — To confine dressings upon the thorax ; to restrain 
the motions of the chest in wounds of this part, or in case 
of fracture of the ribs ; and to secure, by the aid of com- 
presses, the coaptation of the fragments, in the latter injury. 

3. The compressive bandage of Velpeau, consists of a 
roller seven or eight yards long and three inches wide. 

Application. — Let about two feet of the free end of the 
roller hang over the shoulder of the sound side, down the 
back ; then carry the cylinder over the front of the chest, 
below the axilla of the affected side, to surround the thorax 



Fig. 29. 




90 



BANDAGES FOE THE TRUNK. 



with several circular turns, and to confine the pendant portion 
of the roller ; ascend the chest gradually by circular folds, 
each one successively overlapping about two-thirds of the 
preceding; pass the bandage around the axillae in the form 
of the figure 8, and terminate by circular folds ; now, finally, 
raise the pendant extremity of the roller, and crossing it over 
the shoulder of the affected side, attach it to the inferior 
circular turns by pins (fig. 29). 

Use : as of the preceding ; it has the advantage over the 
ordinary circular bandages of the thorax, in being more 
secure, and less easily deranged. 

4. The crossed bandage of the chest, or the figure 8 
bandage of the shoulders. 

Composition. — A roller five yards long and two and a 
half inches wide : cotton, or folded muslin, to protect the 
surface at the axillae, and compresses if indicated. 

Application. — If the object be to approximate the 
shoulders to the sternum, the folds of the bandage should 
cross in front of the chest. Place the free extremity of the 

roller in one of the 
axillae, and pass two 
or three circular turns 
around the thorax ; 
then, the axillae being 
protected by the cot- 
ton, and the shoulders 
drawn towards the 
sternum, by an as- 
sistant, if necessary, 
— traverse the axillae, 
say of the left side, 
and ascend over the 
shoulder from behind 
forwards ; cross the 
front of the chest to 
the right axilla; mount 
over the right shoulder 
from its posterior to 
its anterior face ; de- 
scend obliquely over 
the front of the chest 




BANDAGES FOR THE TRUNK. 91 

to the left axilla, whence repeat the same course as before, 
until four or five folds have been laid upon each shoulder, 
each successive fold, in approaching from the shoulder to the 
neck, overlapping about two-thirds of the preceding. Ter- 
minate the bandage in circular sweeps around the thorax. 
(Fig. 80.) 

If it be desired to draw the shoulders from the breast, it 
can be effected by simply reversing the course of the roller, 
crossing the shoulders from before backwards. 

Use. — To aid in the treatment of wounds of the chest, by 
approximating or withdrawing the shoulders from the sternum, 
as may be indicated by the situation of the wound ; to effect 
pressure upon the clavicular regions, and upon the sternum, 
or back, or in the axillae. 

5. Suspensory for the breast. 

Composition. — Double twice upon itself a piece of linen 
ten inches square, and from the free extremity of each folded 
border cut a triangular portion, of which the apex shall ter- 
minate in the fold ; then open the square and sew the divided 
edges together ; thus, a concave cap is formed adapted to the 
globular conformation of the breast. Attach a piece of tape, 
or a band of muslin, to each angle of the square. 

Application. — Place the cap upon the mamma and confine 
it in situ by tying the two superior bands around the neck, 
and the inferior around the chest below the gland. 

Use. — To support the mamma, and to retain dressings 
upon it. 

6. The triangle-cap for the breast is applied, with the base 
passing just below the mamma, the tails knotted on the poste- 
rior part of the chest, and the apex ascending upon the gland 
to cross over the shoulder of the same side, and be confined 
to the tails, directly or through the intervention of a strip of 
muslin, or tape. 

Use. — As of the last. 

7. The compressive bandage of one breast. 

It will be found exceedingly difficult, if not impossible, en- 
tirely to envelope one of the mammary glands by means of a 
roller, which shall be so applied as not to become deranged 
very soon, and yet to leave the sound breast free; but such a 
concurrence of conditions is frequently desirable. To fulfil 
these indications the following bandage may be employed. 



92 BANDAGES FOR THE TRUNK. 

Composition. — The same as of the suspensory of the mam- 
ma, described above, the degree of concavity of the cap being 
proportioned to the volume and convexity of the gland; gra- 
duated compresses. 

Application. — Place the compresses upon such points of 
the gland as require most pressure, and cover the whole with, 
the cap ; then pass one of the superior bands over the shoul- 
der of the sound side, and the other beneath the axilla of the 
side affected (the surface being protected, if necessary, by cot- 
ton interposed between the bands and the skin) ; knot the two : 
draw the inferior bands around the chest, beneath the breasts, 
and tie them either in front or behind. The degree of pres- 
sure exercised upon the diseased mamma can be easily regu- 
lated by the size of the compresses, and the force with which 
the bands shall be drawn. 

Use. — To effect a regulated compression of the breast, in 
chronic induration or engorgement of this organ, and to obli- 
terate the canals of sinuses, if such exist. 

8. The straight jacket is a garment made of strong but light 
canvass, extending from the root of the neck to the upper 
third of the thigh. It is closed in front, and has straps and 
buckles attached to its posterior borders, or eyelet holes 
worked in them. Along its inner surface sleeves are firmly 
attached, throughout their entire length, open above but closed 
below, and at the proper distance from each other to corres- 
pond with the arms ; opposite the wrists, a slit may be made 
through the jacket, to enable the professional attendant to 
feel the pulse of the patient; shoulder straps should be attached 
to the superior border of the canvass, to prevent the possibility 
of the jacket slipping down, from the efforts of the patient. 

Application. — Insert the arms of the patient into the 
sleeves, and having nicely adapted the jacket to the body, 
draw its borders together behind, and confine them by the 
straps and buckles, or by lacing. 

Use. — To assist in the restriction of the insane, or of those 
who are unmanageable from any cause. 

A very convenient substitute for the straight jacket, and 
one which, while it is equally secure, is less irksome to the pa- 
tient, may be found in a pair of leather mittens, made suffi- 
ciently loose to be easy to the hand, and slit at the wrist so 
that, after the hand is introduced, one border of the wrist- 



BANDAGES FOR THE TRUNK. 93 

band, in which a fenestra has been made, shall overlap the 
other, and be confined upon it by an iron loop, which passes 
through the fenestra ; then insert through the loop on each 
wrist a leather strap, having a buckle at one end, and enclose 
the waist therewith. 

9. The body-bandage of the abdomen consists of a piece of 
muslin or linen folded to an oblong shape, a foot or more in 
width, and long enough to envelope the abdomen ; and of two 
narrow straps sewed to its inferior posterior margin, to serve 
as thigh-straps. 

Application. — Place the centre of the bandage upon the 
median line of the loins, and bring its extremities round to the 
front of the abdomen, where they should be overlapped and 
pinned; then draw the thigh-straps to the front along the 
perineum, and attach them to the anterior part of the bandage. 

Use. — To retain surgical dressings, to give support to the 
walls of the abdomen, and to exercise pressure thereon, as in 
umbilical hernia; in the latter case a graduated compress 
should be employed to assist the compressive action of the 
bandage. 

There are many cases, however, in which a bandage formed 
of a plain piece of muslin, will not support the walls of the 
abdomen sufficiently well. In order to effect this object more 
satisfactorily, an apparatus should be made resembling the 
corsets of ladies ; adapted to the conformation of the belly, 
and rendered firm, and yet elastic, by the introduction into its 
folds of strips of whalebone. Its inferior margin in front 
should be curved, to correspond with the shape of the lower 
part of the abdominal parietes, so that, by being properly 
laced in front or behind, either a uniform pressure, diffused 
equally over the whole surface, can be effected, or a more par- 
tial action may be exerted in a particular direction. 

An apparatus of this sort will be found applicable to many 
cases : in umbilical hernia, in ascites, in pregnancy, and in 
other instances of abdominal distension, a very agreeable sup- 
port will be afforded by its use ; and very considerable, if not 
complete, relief will be given to symptoms simulating, and 
sometimes, perhaps, depending upon prolapsus uteri, or other 
displacements of this organ ; such, for example, as dragging 
pain and weight in the pelvis, a sense of exhaustion, of " fall- 
ing-in of the belly," of faintness, &c, &c. 



94 



BANDAGES FOR THE TRUNK. 



Fig. 31. 



The annexed drawing of an apparatus of this kind is copied 
from Velpeau, (fig. 81). 

10. The posterior 
pelvic triangle, of 
Mayor, is applied 
-with the base along 
the top of the sacrum, 
and the apex de- 
pending over this 
bone : the tails are 
brought round to the 
front of the abdomen 
and knotted, and the 
apex passed between 
the thighs, along the 
perineum, and pubis, 
to be attached to the 
tails. 

Use. — To retain 
dressings upon the 
sacrum and peri- 
neum. 

11. The anterior 
pelvic triangle has 

the base applied to the abdomen just above the pubis, while 
the apex passes from before backwards between the thighs, to 
be attached to the tails which are tied upon the sacrum. 

Use. — To confine applications to the pubis or genitals, or 
simply to cover these parts. 

12. The triangular bandage for the groin is composed of a 
piece of muslin of a triangular shape, and sufficiently large to 
extend from the median line of the abdomen to the fold of 
the groin : to the base is sewed a band long enough to pass 
around the abdomen, and to the apex another band of about 
the same length. 

Application. — Place the triangle upon the groin, the apex 
pointing downwards ; tie the superior band around the waist, 
and bring the inferior round the thigh, from before backwards, 
to be pinned to the first, opposite the centre of the base of 
the triangle. (Fig. 32.) 

Use. — To retain dressings upon the groin. 




BANDAGES FOR THE TRUNK. 



95 



13. The cruro-inguinal triangle, of Mayor. 
Application. — Dispose the base, a, a, so that it shall run 
obliquely from the summit of the affected groin to the edge 
of the iliac crest of the opposite side, the apex pointing ob- 
liquely downwards along the groin ; wrap the inferior tail 
around the thigh of the affected side, from behind forwards, 
and pin its extremity to the body of the triangle, at b ; to the 
superior tail attach a band, e, and carry this around the loins 
to the affected side, down along the fold of the groin, d, cZ, 
crossing the body of the triangle, and the apex, — pinning the 

latter to it, — around the 
posterior and outer as- 
pects of the thigh, to be 
confined at e. (Fig. 33.) 
Use. — As of the last. 

Fig. 33. 



Fig. 32. 





14. The spica of the groin. 

Application. — Place the initial extremity of a roller seven 
yards long and two inches wide, upon the sound side of the 
pelvis, between the anterior spines of the ilium, and confine 
it by circular turns passing around the body, from before 
backwards. After having made two or three circular turns, 
carry the head of the roller obliquely downwards over the 
groin affected, around the posterior aspect of the thigh to the 
ilium again, then across the groin to the opposite side of the 
pelvis, from which it returns to the affected side and repeats 
the same process several times, terminating at length by one 



96 BANDAGES FOR THE TRUNK. 

or two circular turns. Each successive layer of the roller 
should leave exposed about one-third of that which preceded 
it ; see fig. 16, e, e. 

Use. — To confine dressings upon the groin, and to exercise 
some degree of compression upon it, as in chronic glandular 
enlargements and indurations. 

15. The cruro-inguinal cravat, of Mayor, will be found a 
very good substitute for the spica just described, and much 
more simple in its application. 

Place one end of the cravat upon the affected groin, over 
a compress, or not, and conduct the remainder downwards, 
along the groin, to pass between the genitals and the thigh, 
and thus gain the posterior face of the limb ; ascend obliquely 
upwards and outwards over the thigh, cross the affected 
groin, and the end of the cravat already spoken of, to the 
iliac crest of the opposite side ; wind around the loins to the 
ilium of the affected side, pass obliquely downwards along the 
groin, and gain the external face of the thigh, as before, where 
the extremity is to be pinned. 

16. The spica for both groins. 

Application. — Place the initial end of a roller, ten yards 
long and two inches wide, upon the pelvis, as in the single 
spica, and confine it by circular turns running around the 
pelvis from right to left, (this being the most convenient 
course in practice) ; having reached the left side, descend 
along the outer face of the thigh, around it posteriorly, and 
so gain the groin ; then carry the roller upwards over the 
groin to the ilium of the same side, and thence around the 
loins to the opposite groin ; descending this obliquely, pass 
the bandage between the genitals and the thigh, and around 
the limb to mount over its outer face ; cross the right groin, 
and the lower part of the abdomen to the left ilium, and then 
wind around the left groin, and so proceed as before. After 
several turns have been made in this manner, terminate the 
bandage by a few circulars around the pelvis. 

Use. — To effect pressure upon both groins. 

The same object may be attained by the use of cravats. 

17. The double T bandage of the pelvis is prepared from 
a band two or three yards long and three inches wide, 
having sewed to it at right angles, and at a convenient dis- 
tance from one extremity, two other strips, distant from each 



BANDAGES FOR THE TRUNK. 



97 



other about two inches, each being an inch wide and half a- 
yard long. 

Application. — Place the horizontal band so that the ver- 
tical strips shall depend, one on each side of the median line 
of the sacrum. Confine the first by two or three circular 
turns around the body, and draw the vertical bands forwards 
between the thighs, crossing them upon the perineum, to be 
attached to the horizontal strip in front. 

Use. — To retain applications made to the anus, vagina, or 
perineum. 

Instead of two vertical pieces, a single strip may be used, 
half a yard long and as wide as both the others combined, slit 
at its free extremity to near the horizontal portion. 

18. The suspensory of the scrotum may be made of two 
pieces of linen or muslin, or of network, of a 
size varying according to the volume of the 
scrotum. In general, they should be each 
" six inches long and four wide ; the pieces 
being laid together with exactness, two por- 
tions are cut out curvilinearly, as shown in 
the wood cut (fig. 34), by dotted lines ; the 
divided edges from a to b being sewed to- 
gether, a sort of bag is formed, which pre- 
sents at the middle of its upper part an opening, / (fig. 35), 
through which the penis passes. A 




belt, <?, two inches wide and rather 



Fig. 35. 



longer than is requisite to encircle 
the body twice, is then sewed along 
the upper edges of the bag, as from 
c to d (fig. 34) ; to the superior bor- 
der of this belt, at about two inches 
each way from the centre, are 
attached two small loops of tape or 
riband, 6?, d, fig. 35, and about as 
far again from the centre two mould- 
buttons, e, e. 

" Two bandelettes are next fas- 
tened to the lower angle of the bag, 
each about half a yard long, with 
two button-holes near their free extremities. 

"Application. The penis being engaged in the triangular 




98 



BANDAGES FOR THE TRUNK. 



Fig. 36. 



opening, /, of the bag, and the scrotum perfectly enveloped, 
the belt is carried round the pelvis, and being returned 
through the loops, d* d, is tied above the pubis ; the two 
bandelettes are then passed between the thighs, to ascend 
from the perineum along the inferior borders of the glutei 
muscles, and buttoned to the belt in front, e 9 e. 

" Use. — To support and confine dressings upon the scro- 
tum ; to serve also as points of attachment for other appa- 
ratus. It is chiefly employed in the treatment of swelled 
testicle, hydrocele, and irreducible scrotal hernia." (Cutler, 
pp. 101-2.) 

19. The suspensory triangle of Mayor. 
Application. — Pass a cravat around the abdomen and 

pelvis, and knot it securely. Ap- 
ply the base of a triangle to the 
under part of the scrotum at its 
origin, and draw the tails upwards 
in front of the cravat, to be re- 
flected over its superior edge, be- 
tween it and the abdomen, and tied 
as represented in the annexed fi- 
gure (fig. 36). Carry the apex of 
the triangle upw 7 ards, inserting it 
behind the transverse portion of the 
tails (see fig. 86), between the abdo- 
men and the girdle, to be reflected 
forwards over the superior border 
of the latter and pinned to it. 
Use. — The same as of the last. 

20. Bandage for the penis. 
It is requisite sometimes to make use of some means for 

confining applications upon the penis. For this purpose 
sheath is the most convenient covering. When, however, a 
certain degree of compression is w 7 ishecl for, the organ should 
be enveloped in circular and reversed turns of a piece of tape, 
or some very narrow strip prepared at the time. 

For the compressive bandage of the scrotum, see remarks 
in the section on "adhesive plaster." 




BANDAGES FOR THE UPPER EXTREMITIES. 99 

SECTION III. 
BANDAGES FOR THE UPPER EXTREMITIES. 

1. The axillo-clavicular cravat, of Mayor. 
Application. — Place the centre of the cravat upon the 

axilla, and draw the tails obliquely upwards over the chest, 
one in front and the other behind, to be knotted together 
upon the clavicle of the opposite side. 

Use. — To confine dressings in the axilla. 

This may be varied a little, and still fulfil the same end, 
by crossing the tails of the cravat upon the shoulder of the 
affected side, — the centre being in the axilla, as before, — and 
then conducting them, one in front of and the other behind 
the chest, to the axilla of the sound side, where they are to 
be secured. 

2. The compound bis-axillary cravat is applied, by arrang- 
ing one cravat in the manner first pointed out above ; and 
then placing the centre of a second in the other axilla, its 
tails being conducted obliquely upwards, one before and the 
other behind the chest, to be attached to the tails of the first 
at their point of junction. 

Use. — To retain dressings in both axillae at once. 

3. The crossed bandage of the shoulder and axilla. 
Composition. — A roller eight yards long and two inches 

wide. 

Application. — Confine the initial extremity of the roller 
to the arm of the affected side, by a few circular turns pass- 
ing from before backwards and from without inwards. Then 
carry the roller obliquely upwards over the shoulder of the 
same side, and downwards obliquely over the front of the 
chest to the opposite axilla. From this point, the roller 
should cross the back obliquely upwards to the shoulder of 
the affected side, and, traversing the descending turn, regain 
the arm from which it started. Several crosses may be made 
in the same manner, and the roller terminated by circular- 
sweeps around the arm. 

Use. — To confine applications made to the shoulder, or to 
the axilla, — or to exercise pressure upon these parts, which 
may be aided by the employment of compresses. 



100 BANDAGES FOR THE U'PPER EXTREMITIES. 

4. For the crossed bandage of both shoulders and axillae, 
see Section II. 

5. A sling for the fore-arm. 

h Place the middle of a triangle beneath the fore-arm, with 
the apex towards the elbow; then carry the extremities 
obliquely upwards, the anterior over the shoulder of the 
sound side, and the posterior over that of the affected side, 
and tie them around the neck. 

To suspend the hand and wrist, an oblong piece of linen, 
or muslin, or a cravat, may be employed, and the part placed 
upon its centre ; then tie the lateral portions together, leaving 
the hand loosely confined, and suspend the whole to some 
convenient part of the patient's dress, or to the neck. 

6. The carpo-digito-dorsal triangle, of Mayor. 
Application. — Place the triangle upon the back of the 

hand, its base being upon the wrist, around which the tails 
are to be wrapped and confined ; then, having flexed the 
fingers to the proper degree, draw the apex of the triangle 
over them and attach it to the envelope of the wrist. 

Use. — To approximate the edges of wounds in the palm 
of the hand, or on the palmar surface of the fingers ; also to 
prevent the deformities which are likely to occur from the 
cicatrization of burns on the dorsal aspect of the hand. 

7. The palmo-digito-brachial triangle. 

Application. — Tie a band around the arm, just above the 
condyles of the humerus; then place a triangle upon the 
palmar surface of the hand, its base overlaying the wrist, 
around which the tails are wrapped and confined, — and reflect 
the apex over the fingers and back of the hand, to be attached 
to the extremity of the supra-condyloid band. 

Use. — In transverse wounds of the dorsal aspect of the 
hand and fingers, and in burns of their palmar face. 

8. The spiral bandage of the upper extremity is effected 
by the use of a roller, eight yards long and two and a half, 
inches wide : compresses if required,, 

Application. - — Confine the initial extremity of the roller 
upon the wrist by circular turns passing from the radial to- 
wards the ulnar side, — the hand being supine; traverse the 
palm and the back of the hand obliquely to gain the ends of 
the fingers, and then return to the frsenum of the thumb by 
simple spiral turns : envelope the ball of the thumb and the 



BANDAGES FOR THE UPPER EXTREMITIES. 



101 



wrist by folds in the form of a figure 8, and ascend the 
fore-arm by spiral and reversed sweeps around the part. 
Having reached the elbow, place the arm in the proper posi- 
tion; if straight, continue the spiral and reversed turns to 
the shoulder ; if flexed, cover the elbow with crossed folds in 
the form of the figure 8, and then ascend as before. 

Use. — To envelope the arm, and to make uniform, or 
graduated, compression upon it. Great care is necessary, 
especially in case of injury, to avoid exercising too much 
pressure upon the member, as serious inconveniences and 
accidents have resulted from inattention in this respect. 

9. The spica bandage of the upper part of the arm and 
the shoulder. 

Composition. — A roller, eight yards long and two and a 
half inches wide, with compresses for the axilla of the affected 
side. 

Application. — The right arm being the one which requires 
the bandage, place the roller upon the upper part of the arm, 
so that about two feet of 

its free portion shall de- FlG * 3r< 

pend from the outer side 
of the member; confine it 
in this position by one or 
two spiral and reversed 
turns, passing around the 
limb from its outer towards 
its inner face ; then carry 
the roller up over the outer 
aspect of the shoulder, to 
descend obliquely across 
the chest, in front, to the 
axilla of the sound side, 
and return to the affected 
shoulder along the back of 
the chest : descend into the 
axilla along the front of 
the shoulder, and then 
mount over its posterior 
face to traverse the front 
of the chest, as before ; 

having thus laid several folds, secure the terminal end of the 
9* 




102 BANDAGES FOR THE UPPER EXTREMITIES. 

roller by a pin ; now bring the initial portion of the bandage, 
which was left depending from the posterior face of the arm, 
to the front, over the anterior fold of the axilla and the 
shoulder, and around the back of the neck, to terminate in 
front of the chest, on the sound side, (fig. 37.) 

Use. — To exercise compressing force around the upper 
part of the arm and shoulder. 

10. The spica bandage of the thumb. 

Composition. — A roller three yards long and one inch 
wide. 

Application. — Confine the initial extremity to the wrist 
by circular turns passing from the radial to the ulnar margin, 
the hand being held in a vertical position with the thumb 
above; now carry the roller from the palmar towards the 
dorsal aspect of the thumb, between it and the index finger, 
sweep around the base of the former and the wrist to regain 
the palmar surface of the thumb ; repeat this process until 
the roller is exhausted, and then confine its terminal end. 

Use. — To compress the thumb and to restrain its motions, 
as after dislocation. 

A spica bandage may be applied around any of the fingers, 
after the same manner. 

11. The gauntlet. 

Composition. — A roller eight yards long and an inch wide. 

Application. — Confine the initial extremity to the w T rist 
by a few circular turns, then descend to the tip of each 
finger, successively, by oblique sweeps of the roller, returning 
in spiral and reversed turns to the metacarpophalangeal ar- 
ticulation : terminate the bandage by circulars around the 
body of the hand and the wrist. (Fig. 88.) 

Use. — To prevent the opposed surfaces of the fingers from 
uniting in the cicatrization of burns ; to make general com- 
pression upon the hand, and to assist in the cure of fractures 
and dislocations of its bone 

12. The demi-gauntlet. 

Composition. — A roller five yards long and one inch wide. 

Application. — The hand being prone, confine the initial 
extremity of the bandage about the wrist by circular turns 
passing from its ulnar to its radial side ; then discontinuing 
the circular at the cubital side, carry the roller obliquely 
across the back of the hand to the radial margin of the 



BANDAGES FOR THE UPPER EXTREMITIES. 103 

index finger at the junction of the phalanx with the meta- 
carpus, across the palmar face to the cubital margin, and 
thence around to the radial border of the hand; cross the 



Fig. 38. 





palm to its cubital side, over the back of the hand to the 
index side of the middle finger, around the base of this to its 
cubital aspect and then to the radial border of the hand ; so 
continuing 'until the root of each finger is covered : terminate 
the bandage by a circular sweep around the wrist. (Fig. 39.) 
Use. — A light retaining bandage for the back of the hand* 

13. The triangle cap for the hand. 

Application. — Lay the hand upon the triangle, the base 
overlapping the wrist ; reflect the apex over the extremities 
of the fingers upon the wrist, and secure it in this position 
by wrapping the tails of the triangle around the same part. 

Use. — To retain applications upon the hand, which it 
effects very perfectly and readily. 

14. The cravat bandage for the palm or back of the hand. 
Application. — Place the palm, or the back of the hand, 

upon the centre of the cravat; reflect the tails upon the 



104 BANDAGES FOR THE LOWER EXTREMITY. 

other surface, and cross them ; after which, tie them about 
the wrist. 

Use. — An effectual and convenient retaining bandage for 
the body of the hand. 

15. The perforated bandage of the hand is made of a 
piece of muslin or linen large enough to envelope the hand, 
having attached to its lower margin a band half a yard or 
more in length, and an inch wide, and being perforated 
near its superior border by holes corresponding with the 
fingers. 

Application. — Insert the fingers through their respective 
fenestra, and draw the piece over the hand, enveloping the 
latter neatly and accurately ; secure it thus by the band. 

Use. — Same as of the preceding. 

SECTION IV. 
BANDAGES FOR THE LOWER EXTREMITY. 

1. The cruro-iliac triangle, of Mayor. 
Composition. — A cravat, and a triangle. 
Application. — Knot the cravat around the pelvis, passing 

it just below the crest of the ilium ; place the centre of the 
base of the triangle immediately beneath the great trochanter, 
encompass the thigh with the tails of the bandage, and tie 
their extremities, or confine them with pins ; then raise the 
apex of the triangle, and inserting it between the surface of 
the body and the cravat which girdles the pelvis, reflect it 
back upon the body of the triangle and pin it. 

Use. — To confine applications made upon the gluteal 
region. 

2. The bandage of Scultetus is described fully in Sect. II. 
Chap. I. 

3. The eighteen-tailed bandage for the lower extremity. 
Composition. — Stitch transversely to a band of muslin, of 

sufficient length, and about four inches wide, eighteen other 
strips, three or four inches in width, and long enough to 
make one circuit and a half about the limb ; — the centre of 
each transverse band crossing the vertical, and the individual 
pieces arranged in the same manner as the strips of the ban- 
dage of Scultetus, which it resembles in its application and 
uses ; as before stated, it has the disadvantage of requiring 



BANDAGES FOR THE LOWER EXTREMITY. 105 

the removal of the whole, if a single portion of the bandage 
become deranged or unfit for longer employment ; hence it 
is but little used, the other being preferred. 

4. Invaginated bandages for longitudinal and transverse 
wounds of the thigh. For a description of the composi- 
tion of these, consult Sect. II. Chap. I. Their application 
will be illustrated in the chapter on wounds. 

5. The crossed bandage of the knee. 

Composition. — A roller four yards long and two and a 
half inches wide. 

Application. — Confine the initial extremity upon the 
thigh, just above the knee, by circular turns sweeping around 
the limb from left to right (of the dresser) ; then conduct the 
roller obliquely across the top of the knee to the posterior 
aspect of the leg, around which a circular turn is effected, 
and the roller made to ascend diagonally over the knee, 
crossing the first oblique : having reached the lower part of 
the thigh, a circular turn is made, after which the oblique 
and circular folds alternate with each other in the manner 
described, and the bandage terminates in a circular turn below 
or above the knee. 

r Use. — To exercise compression upon the knee, or to retain 
dressings in this situation. The same object may be attained 
in the popliteal region, by crossing the bandage behind, 
instead of in front. 

It will readily be seen that a triangle, or a cravat, will 
fulfil the same purpose ; the former as a retaining, the latter 
as a compressing bandage, when only a moderate degree of 
force is called for. 

6. Weiss's elastic knee-cap, made of some elastic web, and 
lined with India-rubber cloth, or having strips of India rubber 
inserted between its layers, gives a very agreeable and suffi- 
ciently compressive support to the knee : it is confined about 
the joint by lacing. 

As a substitute for this, the elastic bandage made of wool- 
len yarn knit, — described with the laced bandage, in the 
second section of the first chapter, — may be employed. 

7. The spiral bandage of the lower extremity. 
Composition. — A roller six yards long and two and a half 

inches wide. 

Application. — This maybe accomplished in several ways. 



106 BANDAGES FOR THE LOWER EXTREMITY. 



1st. Confine the initial extremity of the roller around the 
ankle, say of the right leg, by circular turns revolving from 
its outer to its inner side : having reached, in the second cir- 
cular turn, the external malleolus, conduct the roller across 
the instep obliquely to the inner side of the foot, and beneath 
the sole to the little toe ; then retrace the course, covering 
the foot with two or more spiral turns; having regained the 
instep, ascend it obliquely and sweep around the leg from the 
inner to the outer side ; thence cross obliquely to the inner 
margin of the instep, wind beneath the sole and the outer side 
of the foot, in advance of the malleolus, mount over the instep 
to the tibial side of the leg, and then conduct the roller to the 
knee in spiral and reversed turns. If the limb be straight, 
continue the same with a fresh roller, if necessary, until the 
whole limb shall be covered. If, however, the knee be flexed, 
the joint must be enveloped with folds in the form of the figure 
8, and circular if need be ; then ascend the thigh as in the 
other case (fig. 16, d). 

This mode of bandaging the limb is very simple and secure ; 
the only objection to it is that it leaves the heel uncovered ; 
and as this part sometimes swells and becomes painful if left 
exposed while the parts above are protected, it behooves the 
dresser to avoid this difficulty, as in the following mode : 
2d. The right leg being selected, confine the initial extre- 
mity of the roller as above ; then, 
instead of crossing the instep, 
wind around the inner malleolus, 
and over the ridge of the tendo 
Achillisjust above its attachment 
to the heel, over the space between 
the external malleolus and the ex- 
tremity of the heel, and then cross 
the sole of the foot by a single 
oblique sweep, to the great toe ; 
cover the foot from the toes to 
the instep by spiral turns, and 
then wind around the inner side 
of the heel, crossing the space 
between the inner malleolus and 
the point of the calcaneum, over 
the arch of the tendo Achillis to the outer side of the leg, just 



Eig. 40. 




BANDAGES FOR THE LOWER EXTREMITY. 107 

above the malleolus ; now pass over the instep and the point 
of the heel to the instep again, and wind the roller in the 
form of the figure 8, around the leg, the instep, and the sole, 
when, having conducted the bandage to the tibial margin 
of the leg, ascend the limb by spiral and reversed turns 
(fig. 40). 

3d. The French spiral, as it is termed, differs but little 
from the first. It is usually commenced by merely placing 
the initial extremity upon the outer margin of the instep 
(but this is less secure than if it is confined around the ankle); 
now wind obliquely around the foot to the great toe, and 
beneath the sole to the opposite side ; from this point cover 
the foot with spiral and reversed turns, extending as high up 
on the instep as may be consistent with the firmness of the 
bandage, and ascend the leg at once, in spiral and reversed 
sweeps, without enveloping the heel. 

Use. — To restrain the action of the muscles of the leg ; to 
compress the limb uniformly, and to assist in procuring the 
removal of indolent swelling of the soft parts, whether caused 
by serous infiltration, chronic inflammation, or otherwise. 

8. Baynton's bandage for the treatment of ulcers. 

This mode of treatment has been already described in the 
first part of the book, in the course of the remarks on Adhe- 
sive Plaster. For an illustration of its application, see fig. 40. 

9. The laced stocking is made of buckskin, or of some elas- 
tic web. It is formed of two pieces fitted to the shape of the 
limb and sewed together along the back of the leg and the sole 
of the foot : the anterior margins are provided with eyelet 
holes, for the purpose of lacing the stocking when applied ; 
and in order to obviate the inconveniences which might arise 
from the direct contact of the lacing apparatus with the skin, 
a piece of some soft material should be sewed along the inner 
surface of one of these anterior borders. 

Use. — To exert a uniform and equable pressure around the 
leg, particularly in case of varicose veins. 

10. An elastic gaiter for the foot and ankle may be very 
well made of India-rubber cloth, lined with linen or silk, so 
contrived as to correspond with the shape of the part, and 
still be elastic : it should be confined upon the foot by lacing 
along the outer side. 

Use. — To support the foot and ankle after sprains of the 
part, or in chronic intumescence from any cause. 



PAKT III. 

BANDAGES AND APPARATUS EMPLOYED IN THE TREAT- 
MENT OF FRACTURES. 

CHAPTER I. 

GENERAL CONSIDERATIONS ON THE TREATMENT OF FRACTURES. 

The method by which nature effects the cure of a fracture 
is, the formation of what is technically called " The Callus ;" 
the different steps of this process are thus briefly stated by 
Muller, (Physiol., vol. i. p. 454): — "The inflammation which 
ensues immediately after the fracture of a bone affects princi- 
pally the surrounding soft parts, viz., the periosteum, cellular 
tissue, and muscles, which all become enlarged and aggluti- 
nated together, so as to form a firm capsule around the frac- 
ture. On the inner surface of this capsule there is formed, as 
a result of the inflammation, a semi-fluid substance which gra- 
dually acquires more consistence and becomes traversed by 
vessels. A similar substance is effused by the medullary tis- 
sue of the broken bone; and this, together with the substance 
poured out by the capsule, at length coalesces, and forms the 
mass enclosed in the capsule and investing the ends of the 
bone, to which the name of ' substantia intermedia' has been 
given. This substance acquires a fibrous texture, and fills all 
the space between the bones ; while the muscles, cellular tis- 
sue, and periosteum return to their former normal condition. < 
The inflammation does not affect the bone so soon as it does 
the soft parts ; it commences in it at some little distance from 
the fractured extremities, namely, at the part where the bone 
is still invested with periosteum, and at the corresponding 
point in the interior. The bone likewise now pours out a ge- 
latinous exudation, in which vessels become developed, and 

(108) 



TREATMENT OF FRACTURES. 109 

■which continues to grow ; while, on the side by which it is con- 
nected with the bone, it becomes converted into cartilage and 
bone. This new mass — the proper callus, — also occupies to 
a greater or less extent the medullary cavity. On the exte- 
rior, its formation is continued towards the fractured extremi- 
ties, till the exudations of the two portions of bone meet and 
unite. Thus is formed the primitive callus. 

" In the meantime, the surface of the bone unites with the 
capsule formecl by the soft parts and the primitive callus, and 
the margins of the fracture unite with the ' substantia inter- 
media.' Callus, too, is formed, and developes itself at the ex- 
pense of the now ligamentous ' substantia intermedia.' Peri- 
osteum is formed anew on the external uneven surface of the 
callus. 

" The further changes which the callus undergoes after the 
ends of the bone have united, consist in the restoration of the 
medullary cavity in its substance, and in the change of its 
form. The texture of the callus undergoes the same changes 
as the cartilage of bone in ossification. While it is cartilagi- 
nous, it contains the peculiar corpuscles of cartilage ; when it 
ossifies, it assumes the cellular texture of bone." 

According to Dupuytren, the period during which the pro- 
visional callus is being formed, continues until the thirtieth or 
fortieth day. In the subsequent period, the ossification of the 
cartilaginous intersubstance — " substantia intermedia" — takes 
place not before the fourth or sixth month ; the swelling of the 
soft parts having been first removed by absorption, the bony 
mass filling up the medullary canal is likewise absorbed, and 
this cavity restored at the end of six to twelve months. 

According to the observations of Mr. Paget, the provisional 
callus rarely exists in the human subject, excepting in the 
case of those bones which cannot be kept at rest, as the ribs ; 
while it is of common occurrence in the inferior animals. 
(Paget's Lectures on Surgical Pathology, vol. 1.) 

Now, the aim of the surgeon, in the treatment of fractures, 
should be to place and preserve the injured parts in such cir- 
cumstances as shall most conduce to the accomplishment of 
the reparative processes just mentioned. To effect this, three 
steps are necessary : 

1st. To secure the proper apposition of the fragments, if, 
10 



110 TREATMENT OF FRACTURES. 

as is generally the case, the broken ends have suffered 
displacement ; 

2d. To retain the fragments in this position ; 

3d. To prevent or remedy any unpleasant symptoms attend- 
ing or following the fracture. 

The method by which these indications may be best ful- 
filled claims a brief consideration. 

1. The reduction of the fracture is effected by extension 
and counter-extension, the first acting upon the inferior or 
distal fragment, the last on the superior or proximal. 

There is some diversity of opinion respecting the point 
from which the fragments should be operated upon : sur- 
geons of the French school applying the extending force to 
that portion of the limb which articulates with the inferior 
fragment, and the counter-extension to that with which the 
superior is connected ; while the English make the extending 
force upon the lower fragment itself, and the counter-extend- 
ing upon the upper. 

To each of these plans there are objections and disad- 
vantages attached, if exclusively insisted upon. The argu- 
ment urged by the Continental surgeons against the latter, 
viz., that by grasping the muscles which are connected with 
the fragments themselves, the reduction is rendered more 
difficult and more painful, because the muscles are made to 
counteract more vigorously the reducing forces, — is not really 
of much weight. For the efforts made to reduce a fracture 
need never be violent ; the force operates gradually, and is 
exerted mediately or immediately by the hands ; and, more- 
over, the muscular contraction with which the surgeon has to 
contend is induced, probably, by the irritation inflicted upon 
the muscular fibres as the irregular and sharp extremities of 
the fractured bone glide over them, during the action of the 
extending and counter-extending forces, rather than by the 
mere grasping of the muscles by the hands ; and it will, there- 
fore, be excited, whether the forces act upon the broken bone, 
or upon portions of the limb more distant from the seat of 
injury. If the French mode of reduction be practised, the 
surgeon is obliged to overcome the contractile force, not only 
of the muscles directly connected with the broken bone, but 
of those likewise which have their attachments to the more 
distant parts through which he operates. 



TREATMENT OF FRACTURES. Ill 

In reducing a fracture, the surgeon may, therefore, consult 
his convenience as to which mode he shall adopt ; if the thigh 
has been broken, it will be most conveniently reduced by 
acting upon the pelvis, and the ankle and leg just above the 
ankle ; if the fore-arm is the seat of fracture, the injury may 
most easily be remedied, and with least assistance of attend- 
ants, by placing this member upon a proper splint, and ope- 
rating upon the elbow and wrist, the surgeon himself making 
both extension and counter-extension, while the splint, with 
the fore-arm resting upon it, is supported by his knee, or by 
an attendant. 

The amount of force employed in the reduction must be 
adapted, of course, to the resistance to be overcome ; it 
should be gradually and steadily exerted. Much assistance 
will be derived from so arranging the position of the limb as 
that the most powerful muscles — those whose contraction is 
most opposed to the proper restoration of the fragments, — 
shall be shortened, and thus rendered in a measure quiescent : 
i. e., the limb should be more or less flexed ; and after the 
reduction of the fracture has been effected, this flexed posi- 
tion may be maintained, or the limb may be slowly and 
cautiously straightened, as the 'views of the surgeon, with 
regard to the permanent position of the limb during the treat- 
ment, shall dictate. The irritability of the muscles may be 
lessened by the administration of opium, and by distracting 
the patient's attention from his injury, while the reduction is 
being effected. 

The extending force should be made in the direction which 
the limb has assumed since the fracture: and then, as the 
proper line is gradually regained, the traction should coincide 
with it. 

As soon as the natural length of the limb has been re- 
stored, the surgeon should adjust the fragments as accurately 
as possible. To this step the term " coaptation " is commonly 
applied. It is accomplished by pressing gently all around 
the neighbourhood of the seat of fracture, avoiding, as far as 
may be practicable, all pressure directly over and upon the 
fragments, in order not to give pain, and that the soft parts 
immediately in contact with the splintered ends of the bone 
shall not be wounded and irritated, more than may be un- 
avoidable. The points of the fingers should not be used, 



112 TREATMENT OF FRACTURES. 

therefore, but the hand should be laid flatly upon the part, 
and very gentle pressure be gradually made from side to side. 

2. The fracture having been thus reduced, the aim of the 
surgeon is to maintain the fragments in apposition, until con- 
solidation shall have become perfected, or, in other words, to 
preserve these parts in a state of perfect rest. This can be 
accomplished only by mechanical appliances which shall pre- 
vent displacement of the fragments arising either from simple 
muscular contractions, or from external causes, or both. 
There are some exceptional cases from time to time occurring, 
in which, — from the fracture being perfectly transverse, and 
unattended by displacement of the fragments, — it may not 
be absolutely necessary to confine the injured part ; but even 
in such cases, no prudent surgeon would neglect to do so, in 
order to guard against accident or violence. 

The mechanical means of retention employed in the treat- 
ment of fractures consist, of bandages, compresses of various 
forms and sizes, and splints. These will be more particularly 
enumerated and described, when special fractures are treated 
of. 

The operation of these means of reduction and retention 
will be much aided by a proper position of the limb which is 
the seat of the fracture, — that position, namely, which will 
relax the most powerful muscles, connected with either frag- 
ment. The question of position will be more particularly 
referred to in the section on the treatment of fractures of the 
thigh, to which it has more especial reference. 

There are some exclusive plans of treating fractures which 
merit description : these are chiefly, — 1st. The treatment by 
the " immovable apparatus;" and 2d. The hyponarthecic 
method of Sauter and Mayor. 

The first — or the method of treatment by the " immovable 
apparatus," — seems to have been introduced into France 
from Spain, under the auspices of the celebrated Baron 
Larrey. As employed by this surgeon, the mode of its appli- 
cation was to surround the limb — the fracture having been 
reduced, and the limb placed in the straight position, — by 
compresses, of suitable form and dimensions, saturated with a 
mixture of white of egg, comphorated alcohol and subacetate 
of lead, and retained upon the limb by folds of the bandage 
of Scultetus, likewise saturated with the same mixture; the 



TREATMENT OF FRACTURES. 113 

member was kept completely quiescent until the bandage had 
become perfectly stiff and firm, forming a rigid case around 
the limb. (Vidal de Cassis, Trait, de Pathol. Ext. vol. ii. 
237, &c.) 

Since the time of Larrey, several modifications of this 
method of treatment have been originated, and adopted in 
practice. 

M. Seutin, of Belgium, employs the following apparatus : 
it consists of strips of muslin arranged as in the bandage of 
Scultetus ; compresses of old linen, or of lint, and pieces of 
pasteboard softened in boiling water so as to be moulded to 
the limb. In applying this dressing, the fracture is reduced, 
the limb restored, as nearly as possible, to its natural shape, 
and then covered with folds of the bandage of Scultetus, or 
of the simple roller ; upon this a layer of freshly prepared 
starch is applied by the hand, or by me'ans of a brush ; then, 
having filled up the irregularities upon the surface with suit- 
able compresses, the whole is enveloped in several layers of 
the bandage of Scultetus, or of the roller, thoroughly im- 
pregnated with the paste ; for the sake of cleanliness the last 
envelope should be applied dry. 

If there be a wound of the integuments, or if the fracture 
be compound, M. Seutin directs that an aperture, correspond- 
ing in situation with the wound, should be made in the band- 
age, or that the various dressings should not be applied upon 
this point. 

During the thirty-six or forty-eight hours required for the 
hardening of this case, the limb should be retained motionless 
in some secure apparatus. 

At the expiration of from two to four days, M. Seutin 
directs that a slit should be made running longitudinally 
through the entire thickness of the envelope, so as to permit 
of the inspection of the limb ; if its condition be favourable, 
the case is closed again by applying an additional layer or 
two of the starched bandage ; if the parts be too much com- 
pressed, throughout, a longitudinal section is made and a 
strip removed ; or if there be too much pressure upon any 
point merely, only portions of the case are cut away at cor- 
responding points ; after which the apparatus is again secured 
as before. In this way, during the whole duration of the 
10* 



114 TREATMENT OF FRACTURES. 

treatment, the limb should be inspected from time to time, 
and any difficulty remedied. 

As soon as the dressing has become perfectly solid, M. 
Seutin allows the patient — the lower extremity being the seat 
of fracture — to walk about upon crutches, the broken limb 
supported from contact with the ground by a sling attaching 
it to the neck. 

M. Velpeau advocates a plan somewhat different from M. 
Seutin's. The solidifying material which he employs consists 
of one hundred parts of dextrine beaten up w T ith sixty parts 
of comphorated alcohol, to which is added forty parts of hot 
water, and the mixture is then shaken; in two minutes the 
solution is ready for use. Having reduced the fracture, M. 
Velpeau applies a dry roller around the limb, and, after filling 
up the inequalities of the surface by compresses, follows it by 
a roller saturated with the above solution ; sometimes he uses 
also pasteboard splints properly softened and moulded to the 
limb, or, if these be not employed, he applies in succession a 
sufficient number of bandages, previously saturated, to afford 
firm support and protection. The limb is kept at rest until 
the dextrine shall have become dry. 

M. Velpeau makes use of this dressing immediately after 
the occurrence of the injury, notwithstanding the existence 
of swelling and inflammation, considering that the compres- 
sion w r hich the bandage exercises upon the tissues, and the 
perfect immobility in which they are preserved, hasten very 
much the removal of this condition. He treats in this way 
comminuted and compound fractures, in the latter cases 
leaving the wound uncovered by the bandage. Unless some 
symptom occur to demand the removal of the dressing, M. 
Velpeau does not disturb it until the fracture has become 
consolidated. 

M. Laugier employs strong paper instead of muslin, to 
envelope the limb. He cuts this paper into strips arranged 
as in the bandage of Scultetus, and having saturated them 
with the agglutinating mixture, covers the limb, including the 
foot, — if the leg be broken, — - forming thus a firm and un- 
yielding boot. This plan is resorted to immediately, and the 
limb inspected from time to time, as symptoms call for it, in 
which event the apparatus should be adjusted accordingly. 

The "Immovable Apparatus" may be very advantageously 



TREATMENT OF FRACTURES. 115 

and safely used in the treatment of fractures, — particularly 
of the upper extremity, and of the leg, — after the injury has 
been treated in the ordinary way, for a sufficient time to have 
allowed of the cessation of liability to displacement of the 
fragments; in other words, w T hen some degree of firmness has 
taken place. And it offers this great advantage over all 
other plans of treatment, that the individual upon whom it is 
applied may be permitted to walk freely with the aid of 
crutches, — exercising a reasonable caution, of course, — even 
with a broken leg. There are many persons who, from bad 
health, or from the pressing requirements of business, will 
not bear the long confinement to bed which the ordinary 
modes of treating a fracture of the lower extremity require : 
to such this plan is very happily adapted, suitable care being 
impressed upon them. 

If this method is resorted to from the first occurrence of 
the fracture, the limb should be carefully inspected daily, and 
at short intervals should be exposed, particularly until it has 
become quite stiff, otherwise an irremediable degree of de- 
formity may have occurred unsuspected by the surgeon, or 
other accidents equally, or even more, serious. 

Another variety of the immovable apparatus has been re- 
commended by M. Dieffenbach, of Berlin. It is made of 
piaster, poured when fluid upon the part, which has been pre- 
viously denuded of hair and smeared with oil. The case is 
made in several pieces, according to the shape of the limb, 
and when it has become solidified it forms a very unyielding 
envelope. It presents the same advantages and disadvantages 
as the methods already alluded to, and is much less frequently 
employed than the others. (For an account of the mode in 
which it is prepared and applied, the reader is referred to 
Vidal de Cassis, op. cit., vol. ii. p. 240. — Paris, 1846.) 

The second plan of treating fractures, to which allusion 
has been made, is that to which the term "Hyponarthecid 9 
has been applied by M. Mayor, of Lausanne. This method 
was first recommended by M. Sauter, but afterwards more 
fully developed by M. Mayor. The apparatus employed con- 
sists of a piece of board, somewhat wider and longer than 
that division of the limb which may be the seat of the frac- 
ture, and covered with a cushion of about the same dimensions. 
The cushion is stuffed with oat-chaff, and is of sufficient 



116 TREATMENT OF FRACTURES. 

thickness to allow at least one-third of the posterior part of 
the circumference of the limb to sink into it, and receive 
support from it. The fracture having been reduced, the limb 
reposing upon the cushion, if there be but little tendency to 
displacement of the fragments, a wide cravat-shaped bandage 
merely is made to embrace both the splint and the limb, op- 
posite to the seat of the injury ; if this arrangement be found 
insufficient to retain the fragments in apposition, extending 
and counter-extending cravat bands are applied to the limb 
below and above the fracture, and attached to corresponding 
extremities of the board. If the leg be broken, the extending 
band is made to act upon the foot and ankle and confined to 
a foot-board, while the counter-extension is made upon the 
leg just below the knee ; any disposition to lateral displace- 
ment can be remedied by acting upon the fragments by means 
of cravats passing to the sides of the board, one operating 
upon the upper and the other upon the lower fragment; or a 
single cravat may be so applied as to act directly upon the 
angle of displacement, and having its " point d'appui" upon 
the opposite side of the board. 

This apparatus may be stationary, or it may be suspended 
off the bed, — if the leg be broken, — by means of cords at- 
tached to the sides of the board, and allowed to vibrate gently 
in the air. M. Mayor has even permitted his patients to sit 
up in chairs, to the back of which a framework is attached 
arching over in front, with the apparatus suspended from it. 
If the arm be broken, the apparatus is suspended from the 
neck upon the chest, and the limb placed upon it and suitably 
confined by cravats. 

Under the head of special fractures, this apparatus will be 
illustrated. (See fig. 53.) 

The chief advantages which M. Mayor claims for this 
method of treatment are, that it leaves the fractured limb 
constantly open to inspection, that it is very simple in its ar- 
rangement and employment, and that it allows of a certain 
degree and kind of movement of the limb as a whole, with- 
out permitting the fragments of the bone to become displaced; 
this last proposition, however, admits of so much doubt that, 
in most cases, we should dissuade from the employment of 
M. Mayor's method, considering it to be not sufficiently 
secure; indeed the very fact that the apparatus, with the 



TREATMENT OF FRACTURES. 117 

limb upon it, is allowed to execute, and is even arranged for, 
a degree of motion, though it be practised gently and with 
caution, renders some displacement almost certain. 

There are various accidents which are liable to occur, and 
many complications to be met with, in the treatment of frac- 
tures, which render necessary corresponding modifications of 
the methods ordinarily pursued. Such, for example, are ex- 
coriations, and sloughings of different parts of the surface ; 
wounds ; a tendency to particular varieties of displacement : 
these subjects will be more properly attended to in the con- 
sideration of special fractures, when the mode of obviating, 
or remedying, them will be pointed out. As, however, it is 
oftentimes necessary in cases of fracture to subdue inflamma- 
tion, it will be convenient to state here that, the plan to be 
pursued in such circumstances is to apply leeches upon the 
part, if required, and to leave the surface exposed, as much 
as shall be consistent with the proper security of the frag- 
ments, in order that cooling lotions shall be laid upon it, or 
other local antiphlogistic applications. 

Before proceeding to the special bandages and apparatus 
used in the treatment of this class of injuries, it will be pro- 
per to allude to two or three subjects of correlative interest 
and importance. 

When an individual suffers a fracture of the lower ex- 
tremity, — or meets with any injury which incapacitates him 
for walking, the proper mode of removing him to his home, 
or to the hospital, is a serious concern. Generally, it is ne- 
cessary, in such cases, to make use of any means of trans- 
portation which shall chance to present itself, as a window T - 
shutter, a door, or a settee ; but every public institution for 
the relief of the sick should have attached to it, as an im- 
portant part of its apparatus, a vehicle contrived expressly 
for the purpose. This may be made like the ordinary hand- 
barrow, having its body about seven feet long and two and a 
half or three feet wide, provided with a slatted or sacking- 
bottom, and with a mattrass and cushions, and supported off 
the ground upon legs, two feet, or more, in length : when 
used in carrying a patient, two men should be employed, one 
to sustain each extremity. The patient should be extended 
upon the mattrass, the injured part comfortably and securely 
reposing upon the cushions. If one of the extremities be 



118 TREATMENT OF FRACTURES. 

fractured, or otherwise hurt, the limb should be so placed as 
that the painful action of the muscles shall be counteracted, 
as much as possible, by position, and attention should be 
directed, temporarily at least, to any pressing emergency, — 
for example, to the existence of hemorrhage, excessive pain, 
syncope, &c. 

The part which is the seat of the injury, should be exposed 
very gently by cutting off the clothes or other coverings which 
envelope it, rather than by drawing them away ; the panta- 
loons, for instance, should be ripped along the outer seam, 
and the boots divided in the most convenient manner by a 
knife. In cleansing the surface, and in making the necessary 
examinations, delicacy of manipulation should be invariably 
studied, and the infliction of any unnecessary pain scrupu- 
lously avoided. In removing the patient from the litter, and 
in placing him upon the bed, the same care should be exer- 
cised, the injured part being supported by the surgeon 
himself. 

Not the least important desideratum in the treatment of 
those fractures, or other injuries, which require that the 
patient shall lie perfectly quiescent for a considerable length 
of time, is a proper bed, which is rarely to be met with. The 
fracture-bed in general use is an ordinary mattrass firmly and 
smoothly filled, and having a circular aperture cut through 
its centre, to correspond with a similar aperture in the sack- 
ing or floor of the bedstead. When the patient is about to 
have an evacuation, the cushion which covers the hole in the 
mattrass is removed, and a suitable vessel made to slide along 
a double groove, placed across the bottom of the bedstead, to 
receive the passage. The objections to this bed are that, the 
patient is obliged to raise himself, or to be raised, when the 
cushion is withdrawn and replaced, and that after the bed 
has been in use for a short time, it sinks very much in the 
middle, so as no longer to present a flat surface to support 
the body and hips ; both of these are serious objections and 
inconveniences. They may be, in a great measure at least, 
obviated, by employing a bed constructed after the following 
method : the mattrass should be very firmly and evenly filled 
with hair ; it should be five or six inches in thickness, with 
the margins, or border, perpendicular, about seven feet long 
and from four to four and a half feet wide. An oblong sec- 



TREATMENT OF FRACTURES. 119 

tion of about eight inches in width, and extending across the 
middle from one side to the distance of a few inches beyond 
the median line, should be removed, and, after having been 
properly prepared, be arranged so as to be drawn backwards 
and forwards at pleasure upon the floor of the bedstead. The 
bottom of the bedstead should be made of board, and should 
be entire, with a movable section opposite that of the mat- 
trass, corresponding with it in length and breadth, and so 
adapted as always to afford a perfectly firm support to it, 
which may be readily accomplished by allowing the slat to 
play upon a double groove. When an evacuation is to be 
received, one hand of the attendant should be placed under- 
neath the hip of the patient, and the section of the bedstead 
and of the mattrass be withdrawn only so far as to allow the 
passage to take place freely, while the hip still reposes upon 
the edge of the section of the mattrass ; the vessel for receiv- 
ing the evacuation may be supported in any convenient man- 
ner underneath the bedstead. Or an aperture of suitable size 
to permit of the evacuation, but not unnecessarily large, may 
be cut in the centre of the mattrass, and the portion which 
was removed adapted, by a hinge joint on its inferior surface, 
to close the aperture when the evacuation has been accom- 
plished, being kept closed by a movable strip passing across 
the bedstead and constituting part of its floor. 

A very good substitute for the fracture-bed, particularly 
for children, will be found in the clinical frame, such as is 
described in the Appendix of Cutler's treatise on bandaging. 
It consists of a simple framework, of two longitudinal and 
two transverse bars attached at their extremities, about seven 
feet long and a yard wide ; a single piece of canvass, with a 
circular aperture in its centre, is firmly stretched upon it, or 
several strips of webbing are nailed across it, intersecting 
each other in various directions, but leaving a sufficiently 
large vacant space in the middle. The frame thus prepared 
is habitually placed upon the mattrass, having been pre- 
viously covered with a sheet in the centre of which a circular 
hole has been cut, and the patient reposes upon it ; when he 
desires to have a passage, the frame is raised sufficiently off 
the bed, and supported in this position in any convenient and 
secure manner, while the evacuation is received in a proper 
vessel. The frame may be raised by two attendants, or by 



120 TREATMENT OF FRACTURES. 

means of the tripod arrangement of Cutler, which consists of 
three strong bars united by a hinge-joint at their upper 
extremities, and having an iron ring or hook secured to their 
point of union and presenting downwards : through this ring 
a long lever is passed, having attached to one end of it the 
cords by which the frame is suspended, while the force for 
elevating the latter is exerted upon the other extremity : when 
the frame is raised, the lever may be secured in position by 
cords attached to some fixed point. 

b The apparatus of Jenks, of which a description and a 
drawing are given in Gibson's Surgery, vol. i., is more com- 
plicated and very much more costly than the simple contri- 
vance above described : it is, however, a much more perfect 
arrangement, and should be introduced into every hospital. 
But in private practice it is generally sufficient to trust to the 
fracture-bed for adults, and to the simple frame described 
for children, who can be lifted from the bed by mere muscular 
strength. 






CHAPTER II. 

BANDAGES AND DRESSINGS FOR FRACTURES OF THE BONES 
OF THE HEAD AND TRUNK. 



SECTION I. 
FOR FRACTURES OF THE BONES OF THE SKULL AND FACE. 

1. When, in fractures of the cranial bones there is displace- 
ment of the fragments, it is produced by the violence, what- 
ever this may have been, which occasioned the solution of 
continuity, and not, as in similar injuries of the long bones, 
by muscular action. Hence, after the displacement has been 
remedied, — if it be necessary, or advisable to attempt it, — 
bandages are only required for the purpose of protecting the 
injured parts from external irritation, and of retaining such 
dressings as may be applied ; they are, therefore, very simple, 
as for example, strips of adhesive plaster, the triangle of Mayor, 
the T bandage, or an ordinary night-cap, or finally, the recur- 
rent bandage : — these have already been described. 

2. Generally, the same remarks may be extended to frac- 
tures of the facial bones, those of the nose for instance : the 
fragments having been restored as well as possible, to their 
natural positions, they need no bandages to preserve them 
44 in situ;" the latter are serviceable only as retentive or pro- 
tective means. 

3. In fractures of the inferior maxillary bone, however, the 
fragments are almost always displaced, and retained in their 
abnormal situations, by the direct action of the muscles which 
are connected with them, as the digastric, the hyoid, the pte- 
rygoid muscles, &c, &c. ; it becomes necessary, consequently, 
to employ some kind of bandage or apparatus which shall coun- 
teract the influence of these displacing agents. 

The bandages most frequently used for this purpose, and 
which will probably be found sufficient in all cases, — are the 
11 (1*1) 




122 FRACTURES OF THE SKULL AND FACE. 

four-tailed of the chin, and those of Drs. Gibson and Barton, 
of this city. 

1. The four-tailed bandage of the chin. 
Composition. — An oblong piece of stout pasteboard divided 

at each end to within an inch of the middle ; — a four-tailed 
bandage, prepared as directed in the section on bandages of 
the head ; — compresses. 

Application. — The pasteboard, previously softened by im- 
mersion in hot water and moulded to the form of the chin and 
jaw, (fig. 41,) is applied upon the seat of 
Fig. 41. fracture ; then the middle portion of the 

bandage is placed upon the chin, over the 
splint; the two superior tails, #, a, fig. 
20, are carried, one on each side, towards 
the nape of the neck, where they are 
crossed, and then conducted, one along 
each side of the head, obliquely upwards 
and forwards to the forehead, and pinned ; 
the lower tails, 5, 5, are now carried upwards before the ears, 
to the summit of the head, where they in turn are crossed, 
and then returned and confined beneath the chin. (Cutler, 
p. 70.) 

2. The bandage of Professor Gibson, and its application are 
thus described by the author himself: "The surgeon having 
carefully examined the injured parts, and replaced such teeth 
as may have been shaken or loosened, runs his finger along 
the margin of the jaw, models the parts to a proper shape, and 
closes the mouth firmly, making the lower teeth press fairly 
against the upper. Then a cotton or linen compress of mode- 
rate thickness, reaching from the angle of the jaw nearly to 
the chin, is placed beneath and held by an assistant, while the 
surgeon takes a roller, four or five yards long and an inch and 
a half wide, and passes it by several successive turns under 
the jaw, up along the sides of the face and over the head ; 
now changing the course of the bandage, he causes it to pass 
off at a right angle from the perpendicular cast, and to encir- 
cle the temple, occiput, and forehead horizontally by several 
turns ; finally, to render the whole more secure, several addi- 
tional horizontal turns are made around the back of the neck, 
under the ear, along the base of the jaw, and over the point 
of the chin. To prevent the roller from slipping or changing 



FRACTURES OF THE SKULL AND FACE. 123 

its position, a short strip may be secured by a pin to the hori- 
zontal turn that encircles the forehead, and passed backyards 
along the centre of the head as far as the neck, where it must 
be tacked to the lower horizontal turn, — care being taken to 
insert pins at every point at which the roller has crossed. 
This simple method of securing a fractured jaw I have prac- 
ticed very successfully for several years." (Fig. 42.) 

3. Dr. J. R. Barton's bandage. 

Composition. — A roller five yards long and two inches 
wide ; suitable compresses. 

Application. — Place the initial extremity of the roller upon 
the occiput just below its protuberance, and conduct the cy- 
linder obliquely over the centre of the left parietal bone to the 
top of the head ; thence descend across the right temple and 
the zygomatic arch, and pass beneath the chin to the left side 



Fig. 42. 



Fig. 43. 





of the face ; mount over the left zygoma and temple to the 
summit of the cranium, and regain the starting-point at the 
occiput by traversing obliquely the right parietal bone ; next 
wind around the base of the lower jaw on the left side to the 
chin, and thence return to the occiput along the right side of 
the maxilla; repeat the same course, step by step, until the 
roller is spent, and then confine its terminal end. (Fig. 43.) 

These bandages are easily applied, and are very efficacious; 
the pasteboard splint described in connexion with the first, 



124 FRACTURES OF THE BONES OF THE TRUNK. 

will be found to be a very useful adjunct to the two latter. 
The bandage may be made to act upon any particular portion 
of the jaw, as required by the situation of the fracture, by mo- 
difying slightly the course of the roller in its successive turns, 
and by a proper position of the compresses ; a little reflection 
on the part of the dresser will enable him to adapt his means 
of treatment to the ends indicated in each case. 

Mr. Lonsdale invented a complicated apparatus for the 
treatment of a particular case of fracture at the symphysis of 
the lower jaw, in which much difficulty was experienced. He 
found it to answer perfectly in this instance, and in several 
other cases which occurred afterwards. The ends which he 
had in view, and which he gained by this apparatus, were " to 
apply all the force and pressure to the lower jaw alone ; to fix 
the two portions of bone between two parallel forces, by ap- 
plying one on the teeth, and the other under the base of the 
jaw ; lastly, to keep the two portions of bone on the same ver- 
tical plane, by fixing them in a grooved plate placed along the 
teeth. " For the description and illustration of Mr. Lonsdale's 
apparatus, the reader is referred to this gentleman's " Practi- 
cal Treatise on Fractures," p. 234, et seq. ; or to Mr. Cutler's 
book, p. 71, et seq. 

If the fracture be compound, or in a simple fracture com- 
plicated with a wound of the cheek, or chin, the folds of the 
bandage must be so arranged as not to press with too much 
force directly upon the wound, and to allow of the applica- 
tion of suitable dressings, of which the first object is to pro- 
mote immediate closure of the wound. 



SECTION II. 
BANDAGES FOR FRACTURES OF THE BONES OF THE TRUNK. 

1. For fractures of the vertebra. 

The bones of the spinal column are very much screened 
and protected from fracture by their peculiar shape and situ- 
ation ; hence they are rarely broken. When they are thus 
injured, it is most frequently the spinous process which suffers, 
as being the most exposed, and, from its form and structure, 



FRACTURES OF THE BONES OF THE TRUNK. 125 

the most readily broken. But very little displacement fol- 
lows when it is fractured, since it is imbedded in muscles and 
ligaments, and acted upon with equal force from both sides. 
A bandage is not, therefore, really needed in cases of this 
kind ; it is very proper, however, to make use of the roller, 
as exhibited in fig. 29, or of the laced bandage of the chest, 
already described, with compresses placed upon the spinous 
process, in order to insure perfect apposition of the frag- 
ments, and to prevent injury from the movements of the pa- 
tient in bed. The injury done to the spinal medulla is gene- 
rally such as to demand more attention on the part of the 
surgeon than the mere fracture. The condition of the blad- 
der, especially, will require watchfulness, retention of urine 
being a very common accompaniment of the accident, and 
demanding the introduction of the catheter at least twice daily. 
Sloughing of the integuments, wherever pressure falls, is also 
a troublesome complication, and one which should be pre- 
vented, if possible, by frictions of such parts, and by the proper 
adjustment of pillows. 

2. For fractures of the ribs and sternum. 

A little reflection upon the shape and connexions of these 
bones will show that there cannot, as a general rule, be much 
displacement of their fragments when they are broken. The 
ribs are attached to each other both above and below, and 
throughout their entire length, by the intercostal muscles ; 
they are strongly bound to the vertebrae, and connected to the 
sternum in front by a very elastic tissue ; while the sternum is 
itself securely united to the clavicles, and retained "in relief," 
as it were, by the numerous costal arches which subtend it on 
each side. Thus the whole, and each part, are so elastic that 
they regain their original shape, when this has been altered 
in case of fracture, unless the fragments are driven into the 
cavity of the chest by great violence. 

The general indication of treatment in fractures of the ribs 
and sternum is to prevent, as much as practicable, the play 
of the thoracic respiratory muscles, devolving the perform- 
ance of the mechanical acts of respiration upon the diaphragm, 
thereby preserving the broken bones in a state of comparative 
repose. To accomplish this, compresses and a bandage of 
some sort are necessary. The laced or buckled bandage of 
the chest will answer very well in many cases, but generally 
11* 



126 FRACTURES OF THE BONES OF THE TRUNK. 

the roller 13 to be preferred. Its application should be com- 
menced from below, the patient having previously made a 
forcible expiration ; the roller should ascend to the axilla by 
circular turns, made with considerable tightness, and then 
pass obliquely upwards and outwards from the axilla to the 
root of the neck on the opposite side, and down in front of 
the chest, crossing the circular folds of the bandage which it 
serves to secure by means of pins inserted at intervals. The 
roller for this bandage should be about eight yards long and 
three inches wide. 

The proper disposition of the compresses is a matter of 
much importance in the treatment of these fractures. If a 
rib has been broken by force acting upon its anterior portion, 
the solution of continuity has occurred probably near the 
angle, where the anterior and posterior curves meet ; the first 
effect of the violence has been to increase the bend of the 
rib at this region, and finally to rupture its fibres ; of course 
there will be an angular displacement externally, and the 
compress should be applied either directly over the fracture, 
or one should be placed a little anteriorly and another just 
posteriorly to it. But when the force impinges upon the 
angle or side of the rib, if there be any displacement appre- 
ciable, it is probably towards the cavity of the chest, and the 
compresses should be so placed as to restore, if possible, the 
natural curve of the bone, and thus to throw the fragments 
outwards. To effect this object, apply one compress upon 
the rib near its junction with its cartilage, and another near 
its angle, as far posteriorly as may be ; or, as Mr. Lonsdale 
advises, a broad lath or piece of pasteboard, may be laid 
upon the side of the chest and confined by a roller, being 
made to press with especial force upon points remote from the 
seat of fracture. 

If the sternum has been broken, and there be depression 
of one of the fragments, a compress should be laid upon the 
portion which is not depressed, near the line of fracture, and 
another upon the depressed portion of the bone at a point 
remote from the rupture, so that, when the roller is made to 
act forcibly upon the two, the first fragment will be depressed 
and the other elevated, at the broken margin. 

The bandage should be worn four or five weeks. 

3. For fractures of the pelvic bones. These bones are 



FRACTURES OF THE BONES OF THE TRUNK. 127 

very rarely broken, and they are so enveloped, individually 
and collectively, in muscular and ligamentous expansions 
covering their whole surfaces, that in the event of fracture 
there can be but slight displacement, unless when the frag- 
ments are violently forced inwards. 

The indication for the treatment is, of course, to keep the 
fragments at rest. To accomplish this a broad roller should 
be passed firmly around the upper part of the thighs and the 
pelvis, and compresses judiciously applied to enable the band- 
age to act upon particular points, as may be required. Per- 
fect quiescence should be enjoined upon the patient for a 
length of time, — from two to two and a half months. The 
state of the bladder must be carefully attended to. 

In cases of compound fracture of the bones of the head 
and trunk, the dressings must be so applied as not to press 
with too much force upon parts surrounding the wound, other- 
wise sloughing of the integuments may ensue. The bandage 
should cover the wound very lightly, in order that suitable 
applications may be made to it : it is better indeed that the 
bandage for the fracture itself shall leave the wound exposed, 
and that an additional retentive band be employed for such 
dressings as may be called for. 



CHAPTER III. 

ON THE APPARATUS AND DRESSINGS FOR FRACTURES OF THE 
BONES OF THE SHOULDER. 

SECTION I. 

FOR FRACTURES OF THE CLAVICLE. 

The slender proportions and exposed situations of this 
bone render it very liable to be broken ; and in the great 
majority of instances a considerable degree of displacement 
accompanies the fracture ; the exceptional cases are those in 
which the solution of continuity has occurred at the acromial 
extremity of the bone, where the surface is broad and covered 
with ligamentous expansions. But when, as generally hap- 
pens, the fracture has involved the more central portions of 
the clavicle, an angular deformity is produced, presenting an- 
teriorly, the scapular fragment being dragged downwards by 
the weight of the arm, and drawn towards the median line 
of the chest, in front, by the action of the pectoral muscles ; 
the sternal fragment is but little deviated from its natural 
position, being held in place by the combined but counteract- 
ing forces of the sternoclavicular and costo-clavicular liga- 
ments, and of the sterno-cleido-mastoid muscle; the promi- 
nence seen and felt at the point of fracture is due, in most 
cases to the sternal fragment, the scapular portion being 
drawn rather below and behind the other ; sometimes, how- 
ever, the scapular fragment projects in advance of the ster- 
nal. The fracture is usually oblique and simple ; comminuted 
and compound fractures occur, however, at times. 

The indication to be pursued in the treatment of this injury 
is, of course, to reverse the line of displacement of the sca- 
pular segment of the bone ; viz., to force the shoulder, and 
with it the fragment of the clavicle which is attached to it, 
upwards, outwards, and backwards ; and having thus restored 

(128) 



FRACTURES OF THE CLAVICLE. 129 

the natural form of the clavicle, to retain the parts in this 
position until consolidation of the fracture shall have taken 
place. The first, or the reduction, is not difficult ; the last 
demands constant care from the surgeon, and a well-contrived 
apparatus. In regard to this, M. Vidal (de Cassis) says — 
"fracture of the clavicle is almost always followed by de- 
formity;" and he adds very truly, "but this deformity is not 
attended with much inconvenience, and does not seriously 
impair the movements of the limb." In females particularly, 
however, a deformity in so exposed a situation as this, must 
be unpleasant, and every endeavour should be made to pre- 
vent its occurrence. 

It is interesting to trace the progressive steps which have 
been made in the treatment of this injury. " Hippocrates 
considered it necessary merely to draw the shoulder outwards 
and backwards. With this view he directed the patient to 
lie upon some prominent body, the back only being sup- 
ported, while the shoulders were forced backwards and out- 
wards by their simple weight. Paulus OEgineta, in addition 
to this, placed a pad in the axilla. Guy de Chauliac en- 
deavoured to fulfil the same indication by means of a bandage 
applied around the shoulders in the form of the figure 8, 
which plan was generally adopted, and of which many sur- 
geons recommended modifications without, however, increasing 
its efficacy.' ' (See Vidal de Cassis, op. cit., vol. ii. p. 291, 
et seq.) Thus from time to time, until the present day, many 
varieties of apparatus, some of them very complicated, pos- 
sessing different degrees of excellence, have been contrived 
for the treatment of fractures of the clavicle. It was re- 
served, however, for one of our own countrymen, a surgeon 
of this city, Dr. George Fox, — to invent, in the year 1828, 
an apparatus which admirably fulfils every indication, is very 
simple in its construction and application, is more comfort- 
ably borne, perhaps, than any other, and yet leaves the in- 
jured clavicle freely and constantly exposed to the view of 
the surgeon, and for the application of topical remedies, if 
required. 

The apparatus of Dr. Fox consists of a firmly stuffed pad 
of a wedge shape, and about half as long as the humerus, 
having a band attached to each extremity of its upper or 
thickest margin : a sling to suspend the elbow and fore-arm, 



130 FRACTURES OF THE CLAVICLE. 

made of strong muslin, with a cord attached to the humeral 
extremity, and another to each end of the carpal portion ; 
and a ring made of muslin stuffed with cotton to encircle the 
sound shoulder, and serve as means of acting upon and se- 
curing the sling. The apparatus is applied thus : — Pass the 
arm of the uninjured side through the ring, so that the latter 
may surround the shoulder ; press the thick end of the pad 
firmly against the summit of the axilla of the affected side, 
and carry the bands which are attached to it, one in front of 
and the other behind the corresponding shoulder, to cross 
upon the root of the neck and traverse the chest obliquely, 
before and behind, and to be tied to the ring ; then having 
fixed the elbow and the fore-arm corresponding with the frac- 
tured clavicle in the sling, conduct its posterior cord behind 
the thorax, and the two anterior cords in front of it, and 
secure them to the ring. The shoulder can be operated upon 
very powerfully by means of these cords ; it can be thrown 
upwards, or backwards and outwards, to any required degree, 
and one of these motions can be impressed upon it at plea- 
sure, until the surgeon shall be satisfied with the position of 
the fragments. 

Soft pads of cotton should be interposed between the sur- 
face and the apparatus at different points ; and, from time to 
time, when the surgeon re-arranges the dressings, he should 
endeavour to make the pressure bear upon parts of the sur- 
face which have not previously, or recently, been acted upon. 
The point of the elbow will require protection in this way ; 
frequently it is well to make a circular aperture in the sling 
and, having covered it with a flattened mass of cotton, to 
allow the point of the elbow to sink into it. 

If the fracture is comminuted, a compress may be placed 
over the fragments, to assist in the securing of perfect appo- 
sition. 

Fractures of the clavicle, treated by this apparatus, are 
daily dismissed from the Pennsylvania Hospital, and by sur- 
geons in private practice, cured without perceptible deform- 
ity ; and no one who has employed it will be disposed to use 
any other as a substitute. 

The annexed drawing exhibits this dressing as applied. 
(Fig. 44.) A mere inspection of it will show the advantages 
of this apparatus over all others, in the complete performance 



FRACTURES OF THE CLAVICLE. 



131 




of the requisite revolutions of the shoulder, the exposure of 

the injured parts, its 

lightness, and the avoid- Fig. 44. 

ance of impediment to 

respiration, and of pres- 
sure upon the mammary 

glands when it is applied 

to females ; in each of 

these particulars the com- 
plicated bandage of Des- 

sault, which is still used 

by some surgeons, is open 

to serious objection ; the 

same remark is likewise 

applicable to the plan of 

treatment recommended 

and illustrated by M. 

Velpeau (op. cit., vol. i. 

p. 229) ; indeed this must 

be less efficacious than 

the other, since it merely confines, by means of a roller, the 

hand corresponding with the broken clavicle upon the sound 

shoulder, no pad being 

placed in the axilla to 

force the scapular frag- 
ment outwards. (See fig. 

46.) 

As a temporary band- 
age, to be employed 
during the short time ne- 
cessary for the prepara- 
tion of Fox's apparatus, 
if the surgeon have not 
one already made, that 
recommended by Mr. 
Lonsdale may be used. A 
pad, resembling in shape 
that already described, is 
to be secured in the axilla by means of a roller. " The elbow 
is next to be brought before the chest as far as possible, and 
to be held there, while a few turns of the roller are passed 




132 FRACTURES OF THE CLAVICLE. 

around to confine it to the thorax ; a sling is then to be 
applied, which must be made very short, so as to prevent the 
elbow from falling from the position into which it has been 
brought, for upon this depends the whole action of the hume- 
rus on the scapular end of the clavicle." (Lonsdale, op. cit., 
pp. 212, 213.) (Fig. 45.) 

A bandage very similar to this was described by Dr. Brown, 
of New York, in the Philadelphia Medical Recorder of 1821. 
It requires that a pad of a wedge shape shall be confined in 
the axilla by means of a roller, which also fixes the fore-arm, 
previously flexed at an acute angle upon the breast, leaving 
the wrist and hand to be supported by a sling. This band- 
age is described in detail and illustrated by a drawing in the 
Medical Recorder, as above mentioned. 

Many other plans of treatment have been proposed and 
resorted to, but the apparatus of Fox will be found of itself 
sufficient for all cases which may occur. Latterly, an en- 
tirely novel method has been instituted in France by M. 
Guillou ; this gentleman reported it to the Academy of Sci- 
ences of Paris, and the description of his mode of treatment 
was published in full in "L'Abeille M&licale," for October, 
1847 ; the following summary is taken from that journal : 

The apparatus consists of five pieces, — 1st, of a sling 
made of a handkerchief of proper length ; 2d, of a cravat 
folded in the middle ; 3d, of a body-bandage formed of a 
towel; 4th, of a square cushion of linen, thicker in the 
middle than along the margin ; 5th, of a pad for the axilla, 
having a band of about a foot and a half long attached to its 
base on each side. 

In the adjustment of the apparatus, the pad is placed in 
the axilla of the injured side, and secured in this position by 
crossing its bands upon the sound shoulder ; the forearm is 
then thrown behind the back and supported by the sling, 
which is passed around the neck, and made longer or shorter, 
according to the degree of force which it may be necessary 
to exert upon the external fragment of the clavicle, since the 
more the fore-arm is raised, the more the external fragment 
will be thrown outwards, backwards, and upwards ; in order 
to confine the arm securely in this position, the body-bandage 
is applied, to compress the lower part of the humerus against 
the thorax, while the cravat band acts in a similar manner 



FRACTURES OF THE SCAPULA. 133 

upon the upper portion of the arm, being wrapped around 
this part of the humerus, and fastened upon the sound 
shoulder ; to increase the power of the cravat, the square 
cushion is inserted between it and the back, and the cravat 
and the body-bandage are pinned to it. 

M. Guillou has employed this method of treatment for 
some years, and prefers it to all others. 

The author has treated several cases of fracture of the 
clavicle after this method, and has found it to accomplish all 
the indications as well as Fox's apparatus. It is, however, 
rather more irksome to the patient, during the first few days, 
than the dressing of Dr. Fox. The pieces composing the 
latter apparatus may be used instead of those described by 
M. Guillou. 

The duration of treatment of cases of simple fracture of 
the clavicle may be stated at six or eight weeks. 



SECTION II. 
FOR FRACTURES OF THE SCAPULA. 

Viewing merely the prominent situation of the scapula, and 
its rather delicate physical conformation, one would fancy 
that it was particularly subject to breakage; but this is not 
really the case. It reposes upon a soft and yielding bed of 
muscular tissue, and is covered by the same sort of structure, 
so that any force which acts upon the scapular region is de- 
prived of a large part of its capacity to injure, before its in- 
fluence has extended to the bone itself. Even its projecting 
processes, little adapted as they are in themselves to resist 
violence, are sheltered and protected in the same way. 

The parts of the scapula which are most often broken are, 
in the order of frequency, the acromion process, the inferior 
angle of the bone, the body, the coracoid process, and, finally, 
the neck. 

1. Of the body and inferior angle. 

When the body of the scapula is fractured either obliquely 
or transversely, there cannot be much separation or displace- 
ment of the fragments, since its whole surface, both in front 
and posteriorly, is covered by an expansion of muscular 
12 



134 FRACTURES OF THE SCAPULA. 

fibres, having an attachment around the margin of the bone. 
The indication to be kept in view, therefore, in the treatment 
of this accident, is merely to maintain the fragments at rest, 
by preventing the action of the muscles which operate upon 
them directly and indirectly. This object is readily and 
completely attained, by applying over the body of the scapula 
a broad compress, and securing it in this situation by passing 
a wide roller around the chest ; the arm should be kept at rest 
in the flexed position, supported in a sling, and confined upon 
the breast. 

When a fracture separates the inferior angle from its con- 
nexion with the body of the scapula, the former is more or 
less drawn away from the latter by the action of the teres 
major muscle. Hence, in the treatment of this fracture, the 
arm should be carried backwards towards the scapula, in order 
to relax this muscle, and confined in this position by means 
of a broad roller, which shall likewise press upon the body of 
the bone and its inferior angle, — the fragments having been 
put in apposition, — by the intervention of compresses placed 
directly upon these parts. The fore-arm should be supported 
by a sling. 

2. Of the coracoid process. 

This portion of the scapula is placed very much out of the 
reach of injury, yet it is occasionally broken. When frac- 
tured, a certain amount of displacement will probably occur 
as a result of the action of the three muscles attached to it, 
viz., the pectoralis minor, the coraco-brachialis, and the short 
head of the biceps, whose combined agency will drag the frag- 
ment downwards and somewhat inwards, towards the point of 
origin of the smaller pectoral muscle. 

To re-adjust the fragments, the above-named muscles must 
be relaxed, and some small compression made over the broken 
process. The fore-arm should be flexed to an acute angle and 
supported upon the breast, the hand of the injured side rest- 
ing upon the sound shoulder, while a graduated compress is 
confined over the natural situation of the coracoid process by 
means of the spica bandage (fig. 37). Or the bandage which 
M. Velpeau recommends for the treatment of fractures of the 
clavicle (op. cit., p. 229), will fulfil the same indications very 
well; thus: select a roller from ten to twelve yards long and 
two and a half inches wide, and apply its initial extremity to 



FRACTURES OF THE SCAPULA. 



135 



the axilla of the sound side; then conduct the cylinder 
obliquely upwards over the back to the affected shoulder, 
place the hand of this side upon the opposite shoulder, the 
fore-arm reposing upon the chest, and continue the roller over 
the clavicle of the injured side, across the upper part of the 
arm to the outside of the same, and so under the arm, the 
elbow and the fore-arm to the axilla of the sound side ; from 
this point, repeat the same course until several turns have 
been made in doloires opening towards the point of the 
shoulder. Having reached the axilla after the fourth or fifth 
fold, continue the roller in circular sweeps passing horizontally 
around the back, the axilla of the injured side, the arm, elbow 
and fore-arm, and thus alternate the oblique and horizontal 
turns until the roller is exhausted. In order to make the 
folds secure, insert pins at the different points of crossing, or 
cover the whole with the starch or dextrine solution. A 

Fig. 46. 




136 



FRACTURES OF THE SCAPULA. 



graduated compress applied upon the coracoid process, before 
crossing it with the roller, will adapt this bandage more per- 
fectly to this particular fracture (fig. 46). 

3. Of the acromion process and the neck of the scapula. 
When the neck of the bone is separated from the body, it 
is drawn downwards by the weight of the arm, and the course 
of treatment is at once rendered manifest, viz., to apply such 
a dressing as shall restore the bone to its natural situation 
and preserve its apposition with the main fragment. A pad 
should be placed in the axilla against the head of the humerus 
and firmly supported, while the shoulder is raised and the 
arm maintained in repose upon the breast, with the fore-arm 
flexed. Fox's apparatus for fractures of the clavicle fulfils all 
the indications very perfectly. (See fracture of the clavicle.) 
When the acromion process is broken, the weight of the 
arm, as in the other case, draws the fragment from its natural 
position, and the same kind of treatment is indicated, with 
the addition of a certain degree of compression upon the pro- 
cess itself. The apparatus of Dr. Fox is applicable to this 
injury, also — with a figure-8 bandage applied to act upon a 
compress placed upon the acromion process (see crossed ban- 
dage of shoulder and axilla) ; or the mode of dressing recom- 
mended by Mr. Lonsdale will fulfil the indications very ele- 
gantly. The process may 
be steadied by the spica 
bandage, which is to be 
applied over the shoulder 
and then under the axilla 
of the affected side, &c, 
&c, until the roller is 
nearly exhausted. The 
last part of the bandage 
may be made to cross the 
shoulder, to descend in 
front and pass under the 
elbow and lower part of 
the fore-arm, by which 
means any degree of pres- 
sure can be made upwards 
with the head of the hu- 
merus, by simply shortening that portion of the roller which 



Fig. 47. 




FRACTURES OF THE SCAPULA. 137 

passes under the elbow. The wood-cut (fig. 47) represents 
this bandage applied. (Lonsdale, p. 202, 3.) It will be seen 
at once that, by regulating the length of the sling on which 
the elbow reposes, and allowing the wrist and hand to droop 
more, or less, as may be required in each particular case, the 
degree of pressure upwards against the acromion process 
may be much modified. This bandage of Mr. Lonsdale 
is open to the objection, that it does not sufficiently confine 
the arm. 

The bandage of Velpeau, above described, will also answer 
very well for the treatment of this fracture. (Fig. 46.) 

After fractures of the scapula, generally, the parts should 
be kept at rest in a secure apparatus for six or eight weeks, 
and when the neck of the bone is detached from the body, a 
longer time is required to complete the union ; Sir A. Cooper 
fixes it at from ten to twelve weeks. But as soon as the 
fragments have become so far united, as that there is no per- 
ceptible motion between them, upon careful and gentle hand- 
ling, passive motion should be resorted to : this is particularly 
important in fracture of the neck of the scapula, for, if the 
shoulder-joint is allowed to remain perfectly motionless 
during the ten or twelve weeks which are requisite for entire 
solidification of the fracture, the head of the humerus will be 
found to have become so firmly fixed in its socket, that ano- 
ther series of weeks will be required to restore to the joint its 
ease of motion. 

In compound fractures of the scapula and clavicle, an object 
of primary importance is, as in all other compound fractures, 
to convert the injury as speedily as possible into a case of 
simple fracture, by inducing closure of the wound by the first 
intention. The mode of effecting this is the same as in other 
similar injuries : by approximating the edges of the wound, 
and retaining them in contact by adhesive plaster. If the 
surgeon fails of accomplishing this purpose, and suppura- 
tion ensues, the poultice, or the water-dressing, must be 
substituted. 



12 



CHAPTER IV. 

ON THE APPARATUS AND DRESSINGS FOR FRACTURES OF THE 
BONES OF THE UPPER EXTREMITY. 

SECTION I. 
FOR FRACTURES OF THE HUMERUS. 

It is in fractures of the long bones of the extremities, that 
displacements are most frequent and most varied in direction ; 
for these bones are acted upon at different points of their 
surface by numerous muscles, having contractile fibres, vary- 
ing in their lengths and in their directions of contraction. 
Hence, in a measure, the great numbers of apparatus which 
have been contrived for the treatment of these injuries. 

The humerus may be broken in its shaft, or at the condy- 
loid, or scapular extremity ; the first is the most frequent seat 
of fracture. 

1. Fracture at the shaft of the bone may occur either 
above, or below, the line of insertion of the deltoid muscle ; 
in either case, there will be displacement of the portions of 
the bone, excepting in rare instances, when the fracture is 
strictly transverse, and has been caused by a force insufficient 
to throw the lower fragment from the axis of the upper ; and 
even if the arm be not shortened, it will probably be some- 
what curved by the action of the muscles, which operate from 
above the fracture upon the lower fragment. 

When the fibres of the bone have been ruptured above the 
insertion of the deltoid, the upper segment will be drawn in- 
wards towards the chest, by the action of the pectoralis 
major, chiefly, while the lower fragment will be drawn up- 
wards and outwards by the combined action of the deltoid, 
and the triceps and biceps muscles. 

If the fracture has occurred below the attachment of the 
deltoid, this muscle will raise the upper fragment outwards, 
while the lower portion will be drawn a little upwards, and 
inwards also with reference to the assumed position of the 

038) 



FRACTURES OF THE HUMERUS. 139 

V 

upper fragment, by the contraction of the muscles which 
pass from the scapula to the lower part of the arm and the 
elbow. 

Whether the shaft of the bone has been broken above, or 
below, the point under consideration, the indications of treat- 
ment will be the same, viz. : to restore the limb to its proper 
length and axis, if these have been altered, and to keep the 
parts at rest. This object will be best accomplished by the 
following plan, which is adapted to both of the supposed 
cases : — Envelope the arm, from the fingers to the axilla, by 
a roller applied so as to make uniform and moderate pressure 
upon the muscles ; then, the arm being carefully supported 
by an assistant, take four splints made of thin wood, — (the 
sides of a cigar-box will answer perfectly well,) — and evenly 
padded w T ith cotton, and apply them separately in front, and 
at the sides of, and behind the arm, and secure them in these 
situations by a roller. The splint for the anterior face of 
the arm should extend from the head of the bone to just 
above the bend of the elbow ; the others from the same point 
to the extremity of the humerus, the projections of the con- 
dyles being carefully protected from too much pressure. 
After the splints have been bandaged to the arm, this should 
be brought a little forwards, so that the fore-arm resting in a 
sling, may be supported on the front of the chest, in the 
flexed position. In order to give greater security to the arm, 
a few circular turns of the roller should confine it to the 
chest. 

If, from any cause, it be desirable to dispense with the 
inner splint, the fracture may be treated equally well, by se- 
curing a wedge-shaped pad in the axilla, the thick end down- 
wards, so as to present a perpendicular surface from the 
glenoid cavity to the extremity of the humerus, upon w r hich the 
latter may rest: then, having applied the roller, and the three 
other splints, as directed above, place the inner surface of the 
arm against the pad, and bandage it to the chest by circular 
sweeps of the roller : the fore-arm should be supported in a 
sling, as above directed. 

Another modification of the same plan consists in substi- 
tuting for the short splint, which is applied upon the inner 
aspect, or on the front of the arm, a rectangular splint, made 
to extend all along the inner or the anterior face of the limb, 



140 



FRACTURES OF THE HUMERUS. 



Fig. 48. 




from the head of the humerus to the ends of the fingers. 
Thus, all motion of the fore-arm will be prevented. 

There is rarely much disposition to great shortening of the 
arm, in fracture of the shaft of the humerus; so that, in the 
vast majority of cases of this accident, the lateral pressure 
effected in the manner just described, is 
amply sufficient to retain the fragments in 
apposition. Mr. Lonsdale, however, has 
met with several cases in which he found it 
necessary to keep up permanent extension 
and counter-extension; and, to accomplish 
this object, he invented a splint which he 
thus describes : — " It consists of a thin bar 
of iron, about an inch and a half wide, and 
long enough to extend from the axilla to the 
elbow, — marked B in the wood-cut. (See 
fig. 48.) The lower end of the bar curves 
upwards underneath the elbow, so as to 
allow of this part of the limb fitting into it, 
at C. This curve terminates in a hook, E, 
for the attachment of a bandage ; and on 
the splint opposite to this hook is a small 
bar, placed across the perpendicular, also 
for the attachment of a bandage. To the 
upper extremity of the splint a crutch is adapted, A, which 
fits underneath the axilla, and is movable up and down, being 
confined at pleasure by means of a small screw, placed at the 
side of the vertical bar." In applying it, the crutch-like ex- 
tremity is secured in the axilla, the upper part of the arm fit- 
ting into it, and the elbow is confined in the inferior curve by 
means of a bandage passing around the limb at the elbow, 
and having attachments to the splint at the hook, and at the 
transverse bar, as already indicated. The whole arm should 
be enveloped by a roller, and one or two lath splints applied 
on the exterior, or anterior, surface of the limb ; the fore- 
arm should be supported in a sling. (Lonsdale, op. cit., 
p. 173, &c.) 

It is very conceivable that a splint of this kind would be 
of much use in cases of compound fracture of the humerus, 
where the limb cannot be wrapped in splints and bandages in 
the usual manner, and where some degree of compression 




FRACTURES OF THE HUMERUS. 141 

and support is required to keep the fragments, in any mea- 
sure, in place. If employed in such cases, the straight 
splints and the enveloping of the limb should he omitted; 
but the arm should be lightly secured to the splint at the 
axilla, and also at the elbow, while another roller, or a band- 
age of Scultetus, shall at once serve to retain the fragments 
in tolerable apposition, to confine upon the seat of fracture 
any proper application, and to support the whole against the 
side of the splint. A little ingenuity on the part of the sur- 
geon will enable him to form a splint of wood, after the pat- 
tern of Mr. Lonsdale, which will answer the purpose equally 
well. But compound fractures of the humerus may be 
treated very well, in most instances, by placing the arm in a 
curved splint made of sheet tin, or of pasteboard, moulded 
to an arm of somewhat larger diameter than that of the 
patient, and well padded ; the limb should be secured to the 
splint, above and below the seat of fracture, by means of a 
roller carefully applied, and leaving the wound exposed ; 
then, by a bandage of Scultetus, a suitable dressing should 
be retained upon the wound, and this part of the arm pressed 
gently against the splint : the fore-arm must be supported as 
usual. 

After a certain time, when the fracture, whether it may 
have been simple or compound, has become tolerably firm, two 
curved splints, made of pasteboard, may be conveniently sub- 
stituted for the ordinary lath splints ; or the immovable appa- 
ratus may be used. The usual time required to insure the 
consolidation of this form of fracture is about six weeks. 

2. Fractures of the upper extremity of the humerus. 

The humerus may be broken either at its surgical neck, 
that portion of the bone, namely, which is included between 
the margin of the articular head and the point of the inser- 
tion of the pectoralis major muscle, or at its anatomical neck, 
a narrow rim of bone separating the curved head from the 
tubercles. Fracture at the surgical neck is much the most 
common. 

When the bone is broken at the anatomical neck, there is 
often little or no displacement, the fractured surfaces being 
so broad at this point. But there is generally some derange- 
ment of the axis of the limb, the lower fragment being drawn 



142 FRACTURES OF THE HUMERUS. 

inwards by the pectoralis major, and upwards by the muscles 
which pass from the scapula to the lower part of the arm. 

The displacement is greater when the fracture occurs at 
the surgical neck, for the upper fragment will be rotated out- 
wards by the supra and infra-spinatus muscles, while the 
lower portion is acted upon as before mentioned. 

In both cases the same indication is to be fulfilled, and it 
will be readily accomplished by confining a pad in the axilla, 
with the thick end downwards, so as to present a plane, per- 
pendicular surface to the shaft of the limb ; then apply a 
roller from the fingers up to the head of the arm, and having 
reduced the fragments to apposition, place a compress over 
the seat of fracture on the outer face of the arm, and upon 
this a curved pasteboard splint extending from the acromion 
process to the outer condyle ; support the fore-arm in a sling, 
and confine the arm to the side of the chest by circular folds 
of a roller passing from the elbow to the shoulder. Or an 
angular splint may also be bandaged to the inner face of the 
arm and fore-arm, the hand being semi-pronated, — and the 
pad used as above. 

The limb should be kept perfectly at rest for six or eight 
weeks, excepting that after the fracture has become sufficiently 
firm, passive motion should be gently made, every day or two, 
as the bandages are freshly applied. 

3. Fractures of the condyloid extremity of the humerus. 

Fig. 49. 




The shaft of the bone may be broken just above the con- 
dyles, as is represented in the annexed drawing (fig. 49), 
taken from Sir A. Cooper's Treatise on Dislocations and 



FRACTURES OF THE HUMERUS. 



143 



Fractures, p. 401, American edition; or the fracture may 
implicate the condyles themselves, " extending in three direc- 
tions : First, the extremity only of either condyle may be 
broken off, as represented at A, in the wood-cut (see fig. 50). 
Secondly, the fracture may include a large portion of one 
condyle only, but extend directly into the joint, as at B. 



Fig. 50. 






Thirdly, both the condyles may be severed from each other, 
and from the shaft of the bone, as well as shown at C." 
(Lonsdale, p. 181.) 

When the solution of continuity has involved the shaft of 
the bone, immediately above the condyles, the lower fragment 
will be drawn upwards and behind the humerus by the contrac- 
tion of the triceps muscle, dragging with it, of course, the fore- 
arm, as represented in fig. 49, — or it may be drawn up on the 
front of the arm, depending, in a great measure, upon the di- 
rection of the force which caused the fracture. The same sort 
of displacement may ensue when the whole of the internal 
condyle is split off, as shown at B, fig. 50, since the ulna will 
be acted upon by the same muscles as in the other case ; but 
there need not be this separation of the fragments, unless the 
violence has been sufficient to rupture the external lateral and 
the capsular ligaments. So also when the external condyle 
alone is severed from its bony connexions, the ligaments may 
still retain it in place, if they have escaped rupture ; and dis- 
placement is still less necessary if the point merely of the in- 
ternal condyle be broken off, as at A, fig. 50. But when, as 
at C, the condyles are not only separated from each other but 
from the shaft of the bone likewise, shortening of the arm is 
an almost certain result, from the operation of the same causes 
as when the shaft of the bone has been fractured above the 
epiphysis. The treatment in every case is pretty much the 
same, although the degree of success which attends it will vary 



144 



FRACTURES OF THE HUMERUS. 



very much, agreeably to the extent to which the joint may 
have been implicated. 

The method recommended by Sir Astley Cooper, when the 
shaft of the bone has been broken as above described, — and, 
with some modifications and additions, it is applicable to the 
other cases, — consists "in bending the arm, and drawing it 
forwards to effect replacement; then a roller should be applied 
while it is in the bent position. The best splint for it is one 
formed at right-angle, the upper portion of which should be 
placed behind the arm, and the lower portion under the fore- 
arm ; a splint must also be placed upon the anterior face of 
the upper arm, and both should be confined by straps : evapo- 
rating lotions should be used, and the fore-arm be kept in the 
flexed position and supported by a sling. In a fortnight, if 
the patient be young, passive motion may be gently begun to 
prevent the occurrence of anchylosis ; and in the adult, at the 
end of 'three w T eeks, a similar treatment should be pursued. 
But even after the most careful and judicious means which 
can be adopted, there is sometimes considerable loss of motion ; 

and when the accident 
has not been understood, 
or has been carelessly 
treated, the deformity 
and loss of motion be- 
come very considera- 
ble." (See fig. 51, in 
which, however, the 
roller should have been 
represented as applied 
to the fore-arm and el- 
bow.) 

The mode of treat- 
ment generally adopted 
in this city consists in 
enveloping the limb, from the fingers to above the line 
of fracture, in a roller, the fore- arm being flexed and the frag- 
ments having been restored to apposition ; then a flat, or 
slightly grooved, rectangular splint is applied upon the ante- 
rior face of the arm, fore-arm, and hand — or upon their inner 
aspect, the hand being semi-pronated, — and secured thus by 
means of a roller, a compress having been placed upon the 



Fig. 51. 




FRACTURES OF THE HUMERUS. 145 

point of the internal condyle if this has been severed : the 
fore-arm should then he supported upon the chest by a sling. 
But if the fracture has involved the articular face of one or 
both condyles, it is advisable, in addition to the splint, to 
give increased support to the posterior face of the elbow. 
For this purpose a piece of pasteboard should be taken, suffi- 
ciently long to extend from three to four inches above the 
elbow, and for the same distance below it, and wide enough 
to envelope the joint laterally; this should be notched at 
different points, so that after it has been softened in hot 
water, it may be made to fit the elbow. Then, the arm 
having been bandaged, as before directed, and the anterior 
splint applied, this cap should be placed upon the posterior 
face of the elbow — care being taken to protect the bony pro- 
jections from great pressure — and confined by the roller which 
secures the other splint. At the end of ten days or two weeks, 
or earlier if all pain has ceased and if the bone has become 
sufficiently firm, passive motion should be resorted to from 
day to day, the condyles being supported by the hand, and 
the angle of the anterior splint changed. After the lapse of 
eight or ten weeks, the confinement may be omitted. It 
should be borne in mind that daily motion of the joint is of 
the greatest importance in the treatment of fractures about 
the elbow, but it should be practised cautiously and with the 
limitations above mentioned. 

When the fracture is compound, the same indications are 
still to be accomplished as when it is simple, and the same 
plan is to be pursued. The splints must be so contrived, 
however, as to allow of frequent inspection and dressing of 
the wound, without requiring the removal of the whole ap- 
paratus. This may be effected by using splints of binders' 
board previously softened and moulded to the shape of the 
part, and large enough to give easy support to the fractured 
limb ; an aperture should be made in the splint opposite the 
wound, sufficiently large to permit of free examination of the 
injury to the soft parts. The limb should be softly cushioned 
in the splints, and secured to them above and below the 
wound, while the particular dressing required for the latter 
may be laid over the aperture corresponding with it in 
situation, and confined by the bandage of Scultetus. Or, 
when the wound is on the anterior face of the arm, the fore- 
13 



146 



FRACTURES OF THE HUMERUS. 



arm may be enveloped in a roller, as in the other cases, and 
a bandage of Scultetus be applied immediately to the upper- 
arm, over the wound, or upon the dressing which covers it, 
while a curved angular splint supports the posterior aspect of 
the whole limb. The fore-arm should be sustained by a sling 
in either case. 

Mr. Mayo contrived a very simple splint for the treatment 
of a case of bad compound fracture of the condyles, by which 
the requisite support was given to the bones, and the wound 
still allowed to discharge freely, and sufficiently exposed to 
be dressed without much disturbance of the limb. As such 
instances sometimes occur, it is well to have an acquaintance 
with the mode employed to treat them, as adopted by so high 
an authority as Mr. Mayo. The apparatus " consists of two 
splints joined together by two small bars, so as to leave a 
space between them for the elbow to fit into. One of the 
splints, B, in the wood-cut, (see fig. 52,) is made for the back 
part of the arm to lie upon, w T hile the other, C, is for the 
forearm ; the second splint terminates in a horizontal portion, 
D, for the hand to rest upon ; the intervening space, A, is 
formed by the two lateral bars, which are slightly curved out- 
wards, to prevent pressure upon the joint." This splint 
should be padded, and the limb secured to it above and below 
the seat of injury, by an ordinary roller, while opposite the 
wound itself the bandage of Scultetus should be used for the 
same purpose, and also to retain suitable dressings upon the 
part. (Lonsdale, p. 189.) 

Fig. 52. 




With regard to the frequency with which the apparatus 
should be removed, and the fracture dressed, in cases of this 
injury generally, only conditional directions can be given. 
If, in a simple fracture, there be no unpleasant symptom or 



FRACTURES OF THE HUMERUS. ■ 147 

appearance after the limb is first dressed, the bandage need 
not be removed for two or three days, and this quiescence of 
the limb is attended with many advantages, especially when 
the fracture has involved the joint directly or indirectly. But 
if the patient should complain of pain in the injured part, the 
envelopes should be removed at least once daily, and the 
injury examined ; unless this attention is practised, sloughing 
of the soft parts, or troublesome excoriations, will often occur. 
The first application of the roller and splints should be made 
carefully, so as to exert only a moderate degree of pressure, 
and to allow of the swelling which follows upon almost every 
fracture ; and the compression made around the lower part 
of the limb should be proportioned to that upon the upper, 
else the soft parts below will become swollen and painful, and 
finally gangrene may ensue. 

In the wards of the Pennsylvania Hospital, in this city, it 
is rare that blood is taken from about the joint in case of 
fracture ; but the fragments are placed in apposition as speed- 
ily as possible, and confined, as above advised, — perfect rest 
being considered a sufficiently powerful antiphlogistic remedy ; 
frequently, indeed, this is aided by the influence of evapo- 
rating or sedative lotions, as diluted spirits, or lead-water. 

In compound fractures, the best local application to the 
seat of injury, after the means hereinbefore advised for the 
promotion of direct closure of the wound have failed, is a 
poultice, or the water-dressing: if the former be used, it 
should be changed at least twice daily, and as much oftener 
as may be required by the amount or nature of the discharge : 
as the wound contracts, and the suppuration becomes very 
scanty, some stimulating lotion, or cerate, may be advanta- 
geously substituted. Passive motion should be resorted to, 
and diligently practised, as soon as the condition of the parts, 
internal and external, will allow; this injunction is of the 
utmost consequence after compound fractures near to, or 
involving, the joint, because it cannot be resorted to so early 
as in simple fractures, owing to the greater length of time 
requisite for the union of the fragments, and because also the 
joint has suffered more, in most cases, than in the other class 
of injury. In both, the rigidity of the parts may be lessened 
by frequently soaking the joint in warm water. 

Comminuted fractures of the humerus require no different 



148 FRACTURES OF THE 

treatment, as a general rule, from the simple, excepting rather 
nicer manipulation in reducing them, and in the application 
of compresses, and a somewhat longer confinement. 



SECTION II. 
FOR FRACTURES OF THE BONES OF THE FORE-ARM. 

The complicated movements of the fore-arm, and the varied 
action of the numerous muscles necessary to effect them, 
occasion, when one or both bones are broken, many forms of 
displacement of the fragments. To remedy these, so as to 
preserve unimpaired the mobility of the limb, it becomes 
necessary for the surgeon to resort to a variety of expedients, 
which it is the object of this section to set forth. 

In fractures of the fore-arm, whether of one or both bones, 
there is one common indication to be fulfilled, excepting when 
the fracture has occurred very near to the extremities of the 
bones ; — this is to preserve the interosseous space, which is 
almost always encroached upon by the fragments. 

1. For fractures of both bones. 

The displacement in these cases may be in the diameter or 
in the length of the fore-arm, or in both directions. Gene- 
rally, there is not much difficulty in retaining the fragments 
in proper apposition after reduction. The mode of accom- 
plishing it, as it is commonly practised, consists in applying 
upon the anterior face of the fore-arm, a long compress which 
fits over the interosseous space, and then placing a straight, 
padded splint, sufficiently long to extend from the elbow to 
the ends of the fingers, upon the front, and another of the 
same length upon the back of the fore-arm, and securing them 
by circular and reverse turns of the roller. The width of the 
splints should be greater than that of the arm, so that the 
convolutions of the bandage shall not press the two bones 
towards each other. 

Sometimes considerable difficulty is experienced in coun- 
teracting a lateral angular displacement : but generally this 
may be overcome by applying a compress of suitable thick- 
ness over the point of deformity, at the side of the fore-arm, 



BONES OF THE FORE-ARM. 149 

and by removing also, if necessary, the compression exercised 
upon the interosseous space at this point. 

After the fore-arm is thus suitably dressed, it is placed in 
a position midway between pronation and supination, — the 
palm of the hand towards the chest, the thumb, which is left 
uncovered, presenting upwards, — and supported in a sling in 
the flexed position. 

Both bones are not commonly broken at the same level, 
but this circumstance does not alter the general mode of 
treatment. 

Mr. Lonsdale objects to this mode of treatment, on the 
ground that the position in which the fore-arm is placed, — 
that of semi-pronation, — is not the one which is most calcu- 
lated to insure perfection in the motions of the limb. The 
muscles which tend to throw the upper fragment of the radius 
in supination, are the supinator radii brevis and the biceps 
flexor cubiti, and, agreeably to Mr. Lonsdale's argument, 
these combined exert more power than the pronator muscle 
which operates upon this fragment, — the pronator radii teres ; 
hence the upper portion of the radius is placed in a much 
more supine position than the lower, if the palm of the hand 
is turned towards the chest, with the thumb presenting 
directly upwards ; and if union of the two fragments of the 
radius takes place in this faulty relative position, the extent 
to which pronation and supination can be effected will be 
impaired, as is not unfrequently noticed. 

To obviate this difficulty, Mr. Lonsdale recommends that 
the hand be placed supine, and that two straight splints be 
bandaged to the fore-arm, precisely as in the ordinary plan of 
treatment ; then the fore-arm should be supported in a sling, 
the elbow approximated to the chest, and the hand projecting 
before the body. 

The splints should be retained for five or six weeks in frac- 
ture occurring to an adult, and for four or five weeks when a 
child is thus injured. I 

In compound fractures of the fore-arm, only one splint can 
be used, as a general rule, with advantage. Tolerably good 
apposition of the fragments can be effected with a single splint, 
by a judicious arrangement of compresses and a roller, or ban- 
dage of Scultetus ; pressure upon the wound itself should be 
13* 



150 



FRACTURES OF THE 



Fig. 53. 



avoided, but, on the contrary, every facility should be offered 
to the escape of the pus. 

The " Ante-Brachial Hyponarthecia," of Sauter and May- 
or is quite well adapted to the treatment of compound frac- 
tures of the fore-arm, of one or both bones. It is thus described 
by M. Cutler : 

" Composition. — A board of convenient width, a little 
longer than the fore-arm and hand, a cushion, a cord for arc- 
loops, and three cravats. 

" Application. — The fracture being reduced, the fore-arm 

is placed upon the cushioned 
board, a, b (fig. 53), which is im- 
mediately suspended from the pa- 
tient's neck by means of the arc- 
loops, e e, — the ring /, and the 
cervical cravat, g. The second 
cravat, <?, is now passed under 
the wrist, and crossed upon the 
back of the hand, the tails being 
then made to embrace the cush- 
ioned board, and knotted at its 
anterior border, as represented 
at h. The third cravat is made 
to pass around the apparatus at 
its upper part, so as to confine the 
corresponding portion of the fore-arm, and is then knotted as 
the other. If it be necessary to counteract any lateral dis- 
placement, a fourth cravat may be made use of, to serve as a 
' traction ligature,' which will of course be knotted at the in- 
ner margin of the suspension-board." This apparatus leaves 
the fore-arm exposed to constant inspection, and suitable dress- 
ings can be applied to the wound without deranging the limb ; 
if the discharge be very profuse, bran may be conveniently 
placed upon the board and around the arm to absorb the pus. 
When the patient lies down, the apparatus should be detached 
from the cervical cravat and placed upon a pillow, or suspended 
from the top of the bed, or from the ceiling. If it be deemed 
expedient, for greater security, to confine the whole limb, it 
can be very easily accomplished by selecting a longer board 
and cushion, extending from the axilla to the extremities of 




BONES OF THE FORE-ARM. 151 

the fingers, and employing a sufficient number of cravats ar- 
ranged after the plan indicated. 

2. For fractures of the radius. 

This bone may be broken at its neck, at its carpal extremity, 
or at any intermediate point. The first and the last cases 
should be treated as if both bones of the fore-arm were broken ; 
the hand may be placed in a state of semi-pronation, or in su- 
pination, as advised by Lonsdale. 

It sometimes happens that the lower fragment of the radius, 
when the fracture is near the carpal extremity, is driven very 
forcibly towards the ulna, so as to require the operation of a 
force gradually exerted, and for a considerable time, to restore 
it to its natural line. For such cases Dupuytren recom- 
mended the following plan of treatment : " Take a bar of 
iron about an inch w T ide and of the length of the fore-arm, 
and which at its lower extremity, opposite the part corre- 
sponding with the wrist, curves downwards in a semicircle, 
to the concavity of which some buttons are placed at equal 
distances." Along the ulnar edge of the fore-arm, place a 
firm compress, extending from just above the extremity of 
the bone upwards, about an inch thick at the lower end, and 
gradually tapering : upon this compress apply the splint, its 
straight portion extending from the elbow to the termination 
of the compress, and secure it in this position by a roller 
which, on reaching the hand, causes the latter to approximate 
the curve of the bar, 

more or less, according FlG - 54 - 

to the amount of force 
required to rectify the 
displacement of the 

lower fragment of the ^V^^^ ^^i IZ^^^^i 

radius, with which the 
hand is connected. 
(See fig. 54.) 

The most common seat of fracture of the radius is at the 
lower or carpal extremity of the bone. Two varieties of this 
accident have been described : one by Dr. Colles, of Dublin, 
in the Edinburgh Medical and Surgical Journal, 1814, and 
the other by Dr. J. R. Barton, in the Philadelphia Medical 
Examiner, 1838. 

Colles' fracture usually occurs from three-fourths to one 





152 FRACTURES OF THE 

inch above the radio-carpal articulation, and is very much 
more commonly transverse than oblique. (R. W. Smith, 
Treatise on Fractures, &c, Dublin, 1847.) Barton s frac- 
ture, on the other hand, extends obliquely into the wrist-joint ; 
and, perhaps in consequence of this implication of the joint 
directly, there is likely to be more inflammation of the articu- 
lation, and more permanent impairment of its motion than in 
case of Colles' fracture. 

The resulting deformity is very much the same in both 
forms of the injury. 

In this accident, the lower fragment of the radius, and 
■with it the carpus, is drawn upwards upon the back of the 
fore-arm, as is represented in the annexed drawing (fig. 55.) 

Fig. 55. 




The treatment as advised by Dr. Barton, is very simple : 
place the fragments in apposition by drawing down the hand, 
the upper part of the fore-arm being fixed; then place a 
compress upon the posterior face of the lower fragment, and 
another on the anterior face of the upper, and apply padded 
splints along the anterior and posterior faces of the fore-arm, 
as directed for the other fractures ; the splints should extend 
from the elbow to the ends of the fingers. After the lapse 
of a week or ten days, passive motion of the wrist and finger- 
joints should be commenced and repeated daily for five or 
six weeks, when the splints may be omitted. When the 
dressings are removed from time to time, the hand, and indeed 
the whole fore-arm also, should be bathed, otherwise the con- 
finement will be attended with want of cleanliness of the 
part, and with a very unpleasant sour smell, disagreeable 
both to the patient and to the surgeon. 

The line of fracture sometimes assumes the opposite direc- 



BONES OF THE FORE -ARM. 



153 



tion, extending from the dorsal face of the radius obliquely 
upwards to its palmar surface. The treatment is the same as 
in the first variety of the injury, a slight change being made 
in the disposition of the compresses to correspond with the 
different kind of deformity, as will at once suggest itself to 
the dresser. 

During the continuance of the splints, and for some time 
later, the fore-arm should be supported in a sling. 

The frequency with which these fractures of the radius 
occur, and the considerable impairment of the mobility of 
the wrist and the finger-joints which result from them, and 
which is sometimes permanent, especially in elderly persons, 
and in those who are subject to chronic rheumatism, have 
induced surgeons to devote a great degree of attention to 
their treatment. Consequently, the simple plan of treatment 
above described, has been variously modified. 

M. Kelaton recommends the following method : Bring 
the fragments into proper apposition by the necessary exten- 
sion, counter-extension, and other manipulations ; place the 
fore-arm in a position midway between pronation and supina- 
tion, the hand being well brought down to its ulnar side ; 
then apply a well padded pistol-shaped wooden splint, extend- 
ing from the elbow to the extremity of the fingers, along the 
outer side of the fore-arm, with a compress opposite the lower 
fragment, and a straight splint along the inner face, reaching 
from the elbow to the wrist, well padded opposite the upper 
fragment, and along the. radial border of the fore-arm, to coun- 
teract the tendency of this part of the bone to pixmation. 
(See fig. 56.) 

Fig. 56. 




154 FRACTURES OF THE 

Dr. Bond, of tins city, has contrived recently a splint, by 
the use of which the liability to stiffness of the joints is very 
much diminished. The splint is made of light wood, cut to 
the shape of the fore-arm, and extends from the elbow to the 
second joint of the fingers. (Fig. 57.) To its palmar ex- 

Fig. 57. 




tremity is to be firmly attached, by screws or nails, a carved 
and rounded block of wood of the size of the patient's hand, 
which the latter may grasp when the arm is extended upon 
the splint. The splint may or may not be, according to fancy, 
or convenience, covered with binders' board, the edges of 
which shall project beyond the sides of the splint, and be 
turned up, so as to form a kind of box for the arm. (Fig. 58.) 

Fig. 58. 




If the binders' board be not used, the splint is wrapped, as 
usual, in a roller or in muslin, the arm is placed upon it, the 
fingers are allowed to rest comfortably, or to be moved at 
pleasure, upon the carved block ; a compress is to be placed 
under the arm at the point of fracture, just large enough to 
fill up any vacuity which the shape of the member may occa- 
sion after the fracture has been reduced. Another compress 
is to be laid upon the dorsal face of the limb, opposite the 
first, and the arm lightly secured to the splint by a roller. 
The patient is permitted to use as much motion of his fingers 



BONES OF THE FORE-ARM. 



155 



and wrist as the apparatus will allow. (See Dr. Bond's paper 
in the American Journal of Medical Sciences, April, 1852.) 

If Dr. Bond's splint be not at hand, (any surgeon, how- 
ever, can make one in a few minutes, of a shingle and a block 
of pine wood), a common splint of the proper length can be 
prepared in imitation of Dr. Bond's, by wrapping a roller 
about it, as recommended by Dr. Hays, and as illustrated 
in the annexed drawing. (Fig. 59.) 

Fig. 59. 




Frequently, patients become wearied of any splint, after a 
certain time, the confinement of the arm in a particular posi- 
tion being irksome to them. If this be the case in the treat- 
ment of these fractures by Bond's, Hays', Nelaton's or Bar- 
ton's plan, the splint suggested by Good, which is applied to 
the back of the fore-arm, may be employed. 

Latterly, it has been proposed by Professor Fauger, of 
Copenhagen, to treat these fractures without splints. " The 
hand having been brought into a position of strong flexion, 
the fore-arm is placed, pronated, on an oblique plane, with 
the carpus highest, the hand being permitted to hang freely 
down the perpendicular end of the plane." (London Lancet, 
May 8, 1847.) 

8. For fractures of the ulna. 

The ulna may be broken in its shaft, or at the coronoid or 
olecranon processes. The first-named variety is treated after 
the same method as when both bones are involved ; fractures 
of the processes require a different plan. 

When the coronoid process is broken off from its bony and 
ligamentous connexions, the brachialis anticus muscle, which 
is inserted upon it, draws it up on the lower portion of the 
humerus; and the chief difficulty in treating this accident 



156 FRACTURES OF THE 

successfully consists in counteracting entirely the force of 
this muscle, so as to maintain the fragments in perfect appo- 
sition. There is also another cause of failure, since when 
this process is detached, " like the head of the thigh-bone, it 
loses its ossific nourishment, and has no other than a liga- 
mentous support. Its life is preserved by the vessels of the 
reflected portion of the capsular ligament upon the end of 
the bone, which do not appear capable of supporting the 
least attempt at ossific union." (Sir A. Cooper, op. cit., 
p. 406.) 

For the treatment of this injury, apply a roller from the 
ends of the fingers, around the fore-arm and about the elbow, 
making firm pressure upon the restored process, through the 
intervention of a compress, and then continue the roller 
around the arm, so as to confine the brachialis anticus : over 
the roller place an angular splint, extending from near the 
the head of the humerus to the fingers, along the anterior 
surface of the limb, and retain it thus by a roller. The fore- 
arm should be supported in a sling, and the apparatus should 
be worn for six or eight weeks, passive motion being resorted 
to very cautiously. The splint which is employed should be 
flexed at rather less than a right angle, in order that the bra- 
chialis anticus may be relaxed as much as possible, and every 
facility be afforded for a bony union of the fragments. 

The angular splints for the upper extremity may be made 
with the angle fixed, or this may be movable and changeable 
at pleasure, the two segments of the splint being fastened at 
the desired angle, by a pin traversing both portions : if the 
former arrangement be adopted, it will be necessary to have 
a multiplicity of splints made at different angles; by the 
latter, the same splint will answer the purposes of all the 
others. 

The olecranon process is more frequently broken than the 
coronoid, and the reparation of the injury is equally, if not 
more, difficult. The triceps muscle acts upon the fragment 
of bone to great advantage, so that when the ligamentous 
fibres are severed, which connect it with surrounding points, 
the retraction is sometimes very great. 

The indication is, of course, to relax the muscle, so that 
the fragments may be kept in apposition ; the fore-arm should 



BONES OF THE FORE-ARM. 157 

be extended upon the arm, and some means should be resorted 
to for securing the broken surfaces together. 

Sir Astley Cooper advises the following plan of treatment : 
— " If there be much swelling and contusion, it is right to 
apply evaporating lotions and leeches for two or three days ; 
and after the inflammation is reduced, a bandage should be 
applied." — "If the swelling and inflammation do not prevent 
it, the surgeon is, at once, to place the arm in a straight posi- 
tion, and to press down the upper portion of the fractured 
olecranon, until he brings it in contact with the ulna ; a piece 
of linen is then laid longitudinally on each side of the joint ; 
a wetted roller is applied above the elbow, and another below 
it ; the extremities of the linen are then to be doubled down 
over the rollers and tightly tied, so as to cause an approxi- 
mation ; thus the portions of bone are brought and held 
together ; a splint well padded is to be applied upon the fore 
part of the arm, to preserve it in a straight position, and con- 
fined to it by a circular bandage ; the whole finally, is to be 
frequently wetted with spirits of wine and water." (See 
fig. 60.) 

Fig. 60. 




" In a month the splint is to be removed, and passive mo- 
tion is to be begun : but, if it be attempted earlier, the ole- 
cranon will be separated from the shaft of the bone, and the 
ligament will become lengthened and weakened ; all attempts 
at motion must, therefore, be made with the greatest gentle- 
ness." (Sir A. Cooper, op. cit., p. 410.) 

Another method of treating this fracture consists in apply- 
ing a roller from the fingers to the elbow, then drawing down 
the fragment of the olecranon to its natural situation ; and 
while an assistant holds it thus, by means of a compress 
placed just above it, the surgeon makes a few figure-8 turns 
around the elbow, permanently confining the compress and 



158 FRACTURES OF THE 

the process of bone, and exhausts the roller upon the upper 
arm. A straight splint is now taken and laid upon the front 
of the limb, extending from near the head of the humerus 
to the wrist ; some cotton should be interposed between the 
splint and the bandage at the bend of the elbow, in order 
to fill up the vacuity at this point, — the fore-arm not being 
extended quite to the utmost, — and the whole secured by an- 
other roller. 

The same precautions, with regard to the institution of 
passive motion, are to be attended to, as in the other 
method. 

The extension of the fore-arm, and the confinement of the 
fragment of the olecranon, may be effected also by the " ole- 
crano-metacarpal cravat" of Mayor, as follows: — Extend 
the fore-arm, and place upon its anterior face a pasteboard 
splint moulded to its form, and reaching from the lower third 
of the upper arm to the fingers ; draw down the fractured 
process to the corresponding surface of the ulna, and upon it 
lay a compress, which should be held by an assistant ; then 
pass a cravat around the lower extremity of the humerus, so 
as to retain in place the splint and the compress, and knot it 
behind, leaving the tails hanging about half way down the 
back of the fore-arm ; to the palm of the hand, below the ball 
of the thumb, apply the centre of another cravat, and tie it 
upon the back of the wrist, thus securing the lower extremity 
of the splint, the tails of the cravat being free ; now tie the 
ends of the two cravats together. (See fig. 61.) 

Fig. 61. 




This method can scarcely be relied upon for the permanent 
treatment of this form of fracture, when the other methods 
can be employed. 

Desault advises that the fore-arm should be maintained in a 



WRIST AND HAND. 159 

state between semi-flexion and extension, in case of fracture 
of the olecranon process, and that a splint slightly curved be 
applied on the anterior face of the limb, as in the plans 
already mentioned. 

In compound fracture of this portion of the bone, the limb 
should be extended by means of a splint laid upon its anterior 
face, and confined thus by a roller, which, however, should not 
cover the wound ; the edges of the latter should be retained in 
apposition by strips of adhesive plaster, and over it a piece 
of lint saturated with blood or solution of starch should be ap- 
plied, the whole being enveloped, and the elbow tightly con- 
fined to the splint, by a bandage of Scultetus. The patient 
should be kept in bed with the arm extended on pillows, the 
hand elevated rather higher than the shoulder. If no unplea- 
sant symptom occur, the dressing should be undisturbed for a 
week or ten days. Treated in this way, these injuries are 
sometimes very well recovered from. But if inflammation and 
suppuration come on, the accident must be treated as ordinary 
compound fractures presenting the same symptoms ; here 
again, adhesive strips properly applied, so as to maintain the 
necessary degree of extension and counter-extension, will be 
found of great service in the treatment. 

Partial fractures of the bones of the fore-arm, those namely 
in which some of the fibres only of the bone are ruptured, the 
others being bent, require the same treatment, in general 
:erms, as the complete fractures. After the line of the bone 
a as been restored, however, by suitable manipulations, there 
is usually less disposition to a reproduction of the deformity, 
and hence less compressing force is required to counteract it ; 
generally, too, union takes place sooner than in the other 
cases, and the splints need not be worn so long as in the 
latter. 



SECTION III. 
FOR FRACTURES OF THE BONES OF THE "WRIST AND HAND. 

1. Fractures of the carpal bones are almost necessarily com- 
pound and attended with much injury to the soft parts; they 






160 FRACTURES OF THE WRIST AND HAND. 

require no especial apparatus to keep tliem in place. The 
best plan of treatment in such cases is, to adapt a splint to 
the lower part of the fore-arm and hand, increasing in width 
at the wrist, being retained lightly in this situation by a roller, 
or bandage of Scultetus ; if the wound is on the palmar sur- 
face of the wrist, the splint should be applied to the back of 
the fore-arm and hand, and vice versa;. If, as is generally the 
case, there is no probability of securing direct closure of the 
wound, poultices, or water-dressings, should be laid upon it, 
at first, or the treatment by irrigation should be adopted, and 
other applications used as required: the fore-arm and hand 
should be supported in a sling, or should repose upon a pillow, 
as most expedient. 

2. Simple fractures of the metacarpal bones are, in gene- 
ral, attended with but little displacement ; after the fragments 
have been restored to apposition, they are easily retained in 
situ by merely laying a compress upon the bone, and confining 
it thus, with the hand and fore-arm upon a broad splint as 
above. 

3. Simple fractures of the bones of the fingers require for 
their treatment merely that the fingers shall be supported by 
a thin strip of pasteboard placed on each side of them, and 
confined by a piece of tape applied in circular turns. For 
greater security and to insure perfect repose to the injured 
finger, the hand and fore-arm should be bound to a splint, as 
in the cases just considered, and supported in a sling. 

4. Compound fractures of the metacarpal and phalangeal 
bones are often met with, as occasioned by the bursting of 
firearms, the explosion of rocks, and by the hand becoming 
entangled in machinery. Such injuries appear very formi- 
dable at first, and as if beyond reparation ; but the hand is of 
such vast importance to the patient, — and the accident gene- 
rally happens to those who earn their subsistence by their 
daily labour, — that an attempt at saving it should be made, 
and the most unpromising cases do very often recover with 
very useful hands. 

A splint long enough to extend from the elbow to the ends 
of the fingers, or a little beyond them, and grooved on its 
palmar portion to receive the fingers (see fig. 62), should be 
padded with cotton, or covered w 7 ith a poultice or other 
suitable dressing, and placed underneath the limb : a roller 



FRACTURES OF THE WRIST AND HAND. 161 

should be passed around the fore-arm and splint, to retain the 
latter in place, and this, with the weight of the dressings that 
are laid upon the hand, will be found in most cases to be suf- 

Fig. 62. 




ficiently retentive for the latter. Generally, the continued 
application of cold water upon the lacerated parts, will prove 
the best and the most agreeable dressing that can be em- 
ployed ; it should be used as advised under the head of irri- 
gation, in the first part of this volume. The feelings of the 
patient form the best guide as to the length of time during 
which this application should be retained ; so long as he finds 
it comfortable, it may be continued ; so soon as he complains 
of increasing pain in the injured part, or if he becomes chilly 
under its use, it will be best to substitute for it a warm poul- 
tice, or folds of soft lint saturated with warm water ; and the 
dressings should be varied to suit the particular conditions of 
the wound. When there is free suppuration, particularly in 
warm weather, the bran dressing will be found very service- 
able, as it not only absorbs the discharges, but covers the 
injured parts and renders it less likely to be infested with 
vermin, — a source of much trouble and annoyance both to 
the surgeon and the patient. (Some of the strong aromatic 
oils are of service in destroying these nuisances ; but it is 
generally necessary to dislodge them from their burrowing- 
places by means of the dissecting forceps, and by injecting a 
stream of water upon them from a small syringe.) 

After the suppuration has in a measure ceased, and the 
wounds have assumed the appearance of healthy ulcers, the 
hand may be placed upon a flat splint, of the same shape as 
the other, and the bones pressed into proper line, by inserting 
pledgets of lint between the fingers and using gentle com- 
pression upon the whole hand by the folds of a bandage of 
Scultetus, enveloping both the hand and the splint ; the ten- 
dency to recurring displacement of the fragments of bone is 
14* 



162 FRACTURES OF THE WRIST AND HAND. 

so slight in these cases, that very little force is requisite to 
keep them in tolerable apposition. 

During the early part of the treatment, the patient should 
be kept in bed, with the arm reposing upon pillows, the hand 
somewhat elevated ; in the latter stages, he may be allowed 
to leave the bed, with the arm supported in a sling. 

The disposition of the pus to run underneath the soft parts, 
forming collections at points remote from the wound, should 
be counteracted by position, by compression, and finally, if it 
can be prevented in no other way, by incisions practised 
wherever a deposit is formed. 



CHAPTER V. 

ON THE APPARATUS AND DRESSINGS FOR FRACTURES OF 
THE BONES OF THE LOWER EXTREMITY. 



SECTION I. 
FOR FRACTURES OF THE OS FEMORIS. 

Greater difficulty is experienced in the treatment of frac- 
tures of the femur, than in those of any other bone. The 
constant action of powerful muscles ; the injurious effects of 
pressure upon the soft parts, from long-continued position, 
and from the compression of bandages ; the hurtful influence 
upon the general health of protracted confinement, and the 
direct impression upon the system resulting from the injury 
itself, are all to be combated in the same case. The attention 
which has been devoted to the consideration of this subject, 
has been proportioned to its importance. 

The proper position in which the thigh shall be maintained 
during the treatment, is the main point of discussion among 
surgeons — some preferring the flexed, others the extended 
position of the limb. A variety of apparatus, more or less 
complicated in structure and arrangement, has been contrived 
with reference to each plan of treatment. 

1. Modes of treatment, the thigh being in the flexed posi- 
tion, — This position is most in vogue in Great Britain ; it was 
first particularly recommended by Mr. Pott, who founded it 
upon the idea that it is possible " to put the limb into such a 
position as shall relax the whole set of muscles belonging to, 
or in connexion with, the broken bone." This idea is mani- 
festly incorrect, since the position which relaxes the flexor 
muscles renders the extensors more tense ; that which approxi- 
mates the extremities of the adductors has the reverse effect 
upon the abductors. 

The following is the plan of treatment adopted by Mr. 

(163) 



164 FRACTURES OF THE OS FEMORIS. 

Pott : — " The position of the fractured os femoris should be 
on its outside, resting on the great trochanter ; the patient's 
whole body should be inclined to the same side ; the knee 
should be in a middle state between perfect flexion and exten- 
sion, or half-bent ; the leg and foot, lying on their outside 
also, should be well supported by smooth pillows, and should 
be rather higher in their level than the thigh; one very broad 
splint of deal, hollowed out and well covered with wool, rag, 
or tow, should be placed under the thigh, from above the 
trochanter quite below the knee ; and another, somewhat 
shorter, should extend from the groin to below the knee on 
the inside, or rather, in this posture, on the upper side. The 
bandage should be of the eighteen-tail kind, and when the 
bone has been well set, and the thigh well placed upon the 
pillow, it should not, without necessity, (which necessity will, 
in this method, seldom occur,) be moved from it again until 
the fracture is united ; and this union will always be accom- 
plished in more or less time, in proportion as the limb shall 
have been more or less disturbed.'' (Cooper's Surg. Diet.) 
The chief and sufficient objections to this plan of treatment 
are, that the means employed are insufficient to keep the 
ends of the fragments in apposition, and too insecure against 
sudden and accidental movements of the limb, or of the 
whole body ; and that the pressure exerted upon the tro- 
chanter for the space of many weeks is too great to be safely 
borne. 

There are some cases, however, in which this position may 
be adopted as a temporary one ; these will be mentioned here- 
after. 

Sir C. Bell recommended another method of treating this 
class of injuries in the flexed position of the thigh : — The pa- 
tient lies upon his back, w T hile the limb is supported upon a 
double inclined plane, one portion of which extends from the 
tuberosity of the ischium to the ham, and the other from the 
ham to the heel ; straight splints are confined to the outer and 
inner sides of the thigh. Numerous apparatus have been 
contrived, in modification of the original suggestion of Bell, 
some of which are much used in England. 

2. The plan of treatment by the straight position of the 
limb was first employed by Desault. In this method, a con- 
stant extending and counter-extending force is maintained 



FRACTURES OF THE OS FEMORIS. 165 

upon the fragments, while lateral pressure is exerted upon the 
limb by means of splints and bandages. The original appa- 
ratus of Desault has been modified and improved upon, in va- 
rious ways, by European and American surgeons, so that frac- 
tures of the thigh may be more successfully treated in the 
straight position, than in any other. 

The os femoris may be broken at its condyloid, or trochan- 
teric extremity, or at any point in its shaft ; and although the 
general plan of treating the injury, at whatever part the frac- 
ture may have occurred, is the same, yet there are some minor 
points of difference, which are nevertheless of importance in 
practice. 

1. For fractures occurring in the shaft of the bone. 

The injury may be simple or compound, and the line of frac- 
ture transverse or oblique. Displacement of the fragments 
almost invariably occurs, even when the bone is transversely 
broken, for the force which caused the fracture nearly always 
deranges the axis of the bone, pushing the two portions from 
contact with each other, and then the muscles have uncon- 
trolled action, and draw the lower fragment upwards, above, 
or underneath, the superior. Even if the contact of the ex- 
tremities of the two portions, at the point of fracture, be not 
completely sundered by the original violence, the muscles 
which pass from the pelvis to the lower extremity of the fe- 
mur will act upon the latter, and thus derange the natural 
line of the bone. But when the fracture is oblique, shorten- 
ing of the limb is a necessary consequence, and its degree will 
depend very much upon the muscular development of the 
patient. 

The solution of continuity may occur at any point between 
the smaller trochanter and the condyles, but its most frequent 
seat is within the lower two-thirds of the bone. The inferior 
fragment is drawn upwards and, generally, inwards by the 
extensor and adductor muscles, while the superior is elevated 
at its lower extremity by the action of the iliacus internus and 
psoas magnus, and this tilting-up of the fragment will be 
greater or less, as the fracture is near to, or remote from, the 
insertion of these muscles. The direction which the upper 
portion of the bone will assume will be modified also by the 
operation upon it of the glutaeus maximus, if the fracture be 
above the middle of the shaft, — it will be thrown outwards. 



166 FRACTURES OF THE OS FE MORIS.' 

And farther there is almost invariably a considerable degree 
of eversion of the foot as well as of the lower end of the upper 
fragment, in consequence of the weight of the limb, or the 
contraction of the external rotator muscles of the thigh. The 
choice and management of the apparatus employed to treat a 
case of fracture of the shaft of the femur must, of course, be 
based upon its adaptation to the counteraction of these causes 
of deformity. It will be most convenient, with reference to 
this point, to consider, first, the different kinds of apparatus 
used in the treatment of these injuries, in the flexed position 
of the limb ; and, secondly, those adapted to the extended 
position. 

The plan proposed by Pott has been already described, and 
the objections to it have been stated : it should not be adopted 
in ordinary cases as a permanent method of treatment, but 
in some instances it may be used with advantage. Thus, 
when there is much contusion of the soft parts, or in cases 
of compound fracture with the wound on the under surface 
of the thigh, as may perhaps happen occasionally, it is the 
only plan which can be resorted to, — temporarily in the first 
class of cases, and as a permanent mode in the latter. 

The apparatus contrived by Sir Charles Bell consisted of 
two boards, ten or eleven inches wide, one of which was made 
to extend from the tuberosity of the ischium to the popliteal 
flexure, and the other from the latter point to the heel : these 
two portions of the apparatus were united at an angle under 
the knee-joint, w 7 hile their other extremities were connected 
by a horizontal piece, which served also to support the 
double inclined plane upon the bed. Holes were pierced 
along the margin of the inclined planes, in which pegs were 
inserted to steady the limb. When about to be used, the 
apparatus was placed upon a mattrass, the inclined surfaces 
covered with a cushion, and the limb laid upon it, so that the 
under surface of the knee should correspond with the angle 
of the plane, and the tuberosity of the ischium should check 
against the upper extremity of the horizontal board. A lath 
splint was bound to the upper surface of the thigh, and 
another along the inner face of the same. 

Many modifications of this simple apparatus have been 
contrived since the original was proposed. Mr. Lonsdale's 
book contains a description of the one which was — at the 



FRACTURES OF THE OS FEMORIS. 



167 



time he wrote, 1888, — in ordinary use at the Middlesex 
Hospital, London, arid which, he thinks, " possesses all the 
advantages that the more complicated ones are said to have." 
It differs from the one just described in having the plane3 
joined by means of a hinge at the point corresponding with 
the knee ; and the same sort of union exists between the 
thigh-piece and the horizontal frame, while the portion on 
which the leg reposes may be fixed at any angle upon the 
latter, by means of a serrated edge. " The letter A marks 
the screw that secures a slide in the thigh-portion of the 
plane, to allow of the latter being adapted to limbs of dif- 
ferent lengths." (See fig. 63.) A slide, having a foot-board 

Fig. 63. 




attached to it, could be very easily adapted to the lower plane, 
so that it might be fastened at a suitable distance from the 
angle, to correspond with the length of the leg. 

In making use of this apparatus, the length of the thigh 
and leg portions of the plane should be made to agree with 
that of the unbroken thigh and leg ; " the points from which 
the measurement should be taken are the tuberosity of the 
ischium and the angle of the knee," and the latter point and 
the heel; "and the plane should be applied to the sound 
limb first, to see that it corresponds exactly with the points 
above mentioned." (Lonsdale, p. 298.) It is advised to 
have the cushion made of flannel folded several times, as this 
is supposed to offer a more smooth and level surface, upon 
which the limb shall rest, than if pillows are employed. The 
whole limb is then gently raised, the thigh and leg being 
flexed, and the seat of fracture carefully supported, the plane, 
having a bandage of Scultetus arranged upon the thigh- 
portion of it, slid underneath, and the limb now lowered 



168 



FRACTURES OP THE OS FEMORIS. 



gradually down upon it. Care should be taken that the 
angle of the knee corresponds exactly with that of the plane, 
and that the tuberosity of the ischium presses well against 
the upper extremity of the apparatus. The hand should be 
passed gently underneath the limb, and the cushion smoothed. 
The proper angle of the plane must be determined by the 
degree of elevation which may be required to make the line 
of the lower fragment level with that of the upper, — the 
latter, as has been already pointed out, being tilted more or 
less upwards by the action of the psoas magnus and iliacus 
internus muscles. An assistant should support the limb 
while the surgeon confines upon the outer, upper, and inner 
aspects of the thigh three splints of the length of the bone, 
by means of the bandage of Scultetus. The limb is secured 
to the plane by a roller, the foot is attached to the foot-board 
by the same means, and the legs are inserted into the holes 
made for them. The annexed drawing, taken from Mr. 
Lonsdale's book, p. 302, "represents the apparatus when 
properly applied. The lines A, B, show the two important 
points that are to be attended to ; — A, that the angle of the 




knee corresponds with the angle of the plane — B, that the 
tuberosity of the ischium presses well against the upper end." 
(See fig. 64.) 

Any disposition to the lateral angular deformity, in conse- 
quence of the gluteus maximus muscle acting upon the upper 



FRACTURES OF THE OS FEMORIS. 169 

fragment, may be easily counteracted, by directing the appa- 
ratus outwardly from the middle line of the body, thus giving 
the lower fragment a direction parallel and continuous with 
that of the upper. 

The chief modification of this simple apparatus is that of 
Mr. Amesbury, who contrived it to remedy the objections 
which appeared to him to be well-founded against the other : 
these objections were, that it allowed of motion of the pelvis, 
and consequently of the upper fragment, thereby disturbing 
the apposition of the broken extremities of the bone, and that 
it did not allow of sufficient extension being made. It will be 
seen, by examining the double inclined plane above described, 
that the pelvis is not well confined, and that the counter- 
extension is effected chiefly by the weight of the body, aided 
by the pressure of the apparatus against the tuberosity of the 
ischium, and by the attachment of the upper fragment to the 
thigh-portion of the plane, — while the extension is made by 
the weight of the leg and its confinement, together with that 
of the foot, to the lower plane and foot-board. 

Dr. Spaulding, of Buffalo, has been very successful in 
treating these injuries by the inclined plane. He fixes the 
pelvis more securely, by allowing the horizontal portion of 
the plane to extend high up, so that the tuberosity of the 
ischium shall rest upon it. 

Mr. Amesbury's apparatus is much more complicated. It 
consists of three parts, exclusive of straight splints and straps : 
one portion, a, corresponds with the thigh, another, Z, with 
the leg, and the third, e, with the foot. (Fig. 65.) There are 

Fig. 65. 




two thigh-pieces to each apparatus, " one is bevelled off at 
the lower end to the right; and the other to the left," to 
render the shape of the upper part of the plane conformable 
15 



170 FRACTURES OF THE OS FEMORIS. 

to that of the thigh, — a perfectly-formed thigh being not 
straight, but curving a little inwards towards the knee. The 
thigh and leg-pieces are connected together by a hinge-joint, 
fastened by a pin, d. The foot-board is fitted upon the lower 
plane at a right angle, and may be fixed at a greater or less 
distance from the angle of the two planes, by means of a pin 
or a screw. The length of the thigh-piece may be adapted 
to any limb, by means of a sliding plate which is arranged at 
its upper part, and which may be fixed as required by a screw. 
The two portions of the plane are connected underneath by a 
steel rod, e, and the angle of the plane may be altered at 
pleasure, by varying the point of fixation of this rod to the 
under surface of the thigh-piece, a rack being there placed 
with several projections, each of which has a hole bored 
through the middle, for the purpose of receiving a bolt, which 
also perforates the extremity of the rod. At the back of the 
sliding plate, a couple of bars are placed, which serve to 
render the plate more secure, and also to confine the pelvis- 
strap which retains the apparatus in apposition with the 
ischium. 

In applying this apparatus, it should first be adapted to the 
sound limb, in order that the proper length may be ascer- 
tained. Then, the requisite angle having been given to the 
planes, and their surfaces smoothly and evenly cushioned by 
means of flannel, the broken limb should be carefully depo- 
sited upon the apparatus, a roller having been previously 

Fig. 66. 




applied from the foot to the knee. The shoe, a (see fig. 66), 
should now be buckled over the foot securely, and the pelvis- 
strap passed between the bars and the plate of the sliding 
portion of the thigh-piece. The leg should be confined to the 



FRACTURES OF THE OS FEMORIS. 171 

lower plane, by a roller, c7, and the fragments of the femur 
properly adjusted, by extension and counter-extension, and 
retained in position by three straight splints, one on the 
outer, £, another on the upper, /, and the third on the inner 
face of the thigh, in which situations they are secured by the 
straps, g, g, g, fixed to the back of the apparatus. " The 
pelvis-strap, A, should now be carried round the limb under 
the strips of leather, on the back of the short splints, and 
made to cross on the outer side, and then the buckle-end with 
the sliding-pad should be conducted round the pelvis, and 
made to meet the other end in front, where it should be 
buckled.''' 

When there is much inflammation, Mr. Amesbury omits 
the front splint, and applies evaporating lotions, &c, &c. 

When the apparatus is thus securely arranged, it may be 
placed on its side, or rest upright. Mr. A., thinks that 
"half way between the side and the heel is a better position 
for a continuance. I generally," he continues, " place the 
apparatus upright, or a very little rolled outwards. It is 
maintained in either of these positions by pillows, assisted by 
a couple of tapes, a, i, carried from the lower end of the 
apparatus to the foot of the bed." 

This apparatus certainly seems to offer much more security 
than the more simple one before described, and by it, accord- 
ing to the testimony of its author and many others, cures are 
effected of fractures of the thigh, without apparent shorten- 
ing of the limb. 

Professor Nathan R. Smith, of Baltimore, has constructed 
a very light and portable double inclined plane, for the treat- 
ment of these injuries, which is believed to be equally valu- 
able and efficacious. A full account of it may be seen in 
<; Gedding's Baltimore Medical and Surgical Journal," vol. i. 
1833. It allows of suspension of the limb, and a gentle 
swinging motion. The annexed figure will convey an idea of 
its construction. (See fig. 67.) 

The inclined plane which seems to be most in vogue in 
England, is M'Intyre's, as modified by Mr. Liston. It con- 
sists of a thigh and leg piece of sheet iron, and a foot- board 
of wood ; the former are connected together by a couple of 
hooks and a screw, which is so placed that the two plates can 
be set to any angle at which it may be desirable to bend the 



172 FRACTURES OF THE OS FEMORIS. 

Fig. 67. 




knee ; and the foot-board is affixed in such a manner, that it 
may be slid upwards or downwards to suit the length of the 
leg, and fastened by a side-screw in any position that maybe 
wished. At the lower end of the apparatus there is a cross 
plate of iron, which is so attached, that if the foot be raised 
or depressed, the plate will always rest flatwise on the mat- 
trass, or a board placed at the foot of the bed for the purpose 
of supporting it. (Fig. 68, taken from Fergusson's book.) 

Fig. 68. 




The hyponarthecia of Mayor and Sauter, is a modification 
of the same principle, — a double inclined plane, upon which 
the thigh and leg are confined, in the same manner as is the 
arm in the hyponarthecia for the upper extremity ; as in the 
latter case, the apparatus is suspended from the bed or ceil- 
ing. Those who would see a drawing of this apparatus, are 
referred to the book of Mayor, to that of Cutler, or to that 
of Dr. H. H. Smith. 

The only way in which any individual can form a satis- 



FRACTURES OF THE OS FE MORIS. 173 

factory opinion, as to the real comparative efficacy of the 
treatment of fractures of the thigh by position, is to test it 
for himself. The statements respecting it are of the most 
opposite kind, and by surgeons of equal eminence, — among 
whom are Amesbury, Lonsdale, Cooper, Bell, Earle, in 
favour of it, while Liston, Fergusson, and most of the con- 
tinental and American surgeons prefer the method by ex- 
tension. 

This latter mode of treatment, as it is now generally prac- 
tised, was proposed by Desault. The apparatus employed 
by him consisted of two straight splints rather broader than 
the antero-posterior diameter of the limb, tapering gradually 
from the upper to the lower end, — one long enough to extend 
from the crest of the ilium to four inches beyond the foot, 
and the other from the perineum to the sole of the foot along 
the inner side of the limb ; near the upper end of the long 
splint a hole was perforated for the attachment of the coun- 
ter-extending band, and a notch was cut at the lower extrem- 
ity, with a perforation just above it, for the securing of the 
extending strap. The rest of the apparatus consisted of a 
splint-cloth ; long pads filled with chaff, to equalize the pres- 
sure of the splints along the outer and inner faces of the 
limb ; a counter-extending band, to pass between the pubis 
and the upper part of the thigh, and to be attached to the 
upper extremity of the long splint, and an extending band, 
for the purpose of firmly connecting the foot with the lower 
end of the same splint ; lateral pressure was made by means 
of several strips of muslin, which drew the splints and the 
pads firmly against the limb on each side, while the thigh was 
enveloped in a bandage of Scultetus. 

The objection to this particular apparatus is, that the ex- 
tending and counter-extending forces do not act sufficiently 
parallel with the axis of the limb. This difficulty is obviated 
by the very simple modification which Dr. Physick made of 
the apparatus of Desault. This consisted in making the 
outer splint long enough to extend from the axilla to about 
four inches beyond the sole of the foot, and in attaching to 
its inner side, at about two inches above its lower end, a 
block, grooved on its inner margin, and broad enough to 
reach the line of the middle of the foot (fig. 69) ; the other 
component parts of the apparatus are the same as are used 
15* 



174 



FRACTURES OF THE OS FEMORIS. 



Fig. 69. ■ 



in Desault's. The counter-extending band is best made by 
filling a narrow bag of muslin, about three-fourths 
of a yard long, firmly with bran, or oat-chaff, so as 
to form a cylinder of an inch in diameter ; to each 
extremity a piece of strong tape should be securely 
sewed, for the purpose of attaching the band to the 
upper extremity of the splint ; when this is applied, 
a piece of soft buckskin should be interposed be- 
tween it and the skin, as a preventive of excoriation 
and chafing. Extension is best effected by means 
of a gaiter, similar in shape to that represented in 
the annexed wood-cut (see fig. 70) ; it should be made 
of strong muslin lined with soft buckskin, both to be 
cut "bias" so that the gaiter will set smoothly to the 
ankle ; stout tapes should be attached to its lower 
edge, one on each side, to make traction upon it and 
to secure it to the splint, and three or four shorter 
tapes should be sewed to each free margin, to tie the 
gaiter upon the anterior part of the foot. Previous 
to its application, the ankle should be bathed with 
whiskey, or soap-liniment, or spirits of camphor, and 
enveloped smoothly in a pad of soft carded cotton ; 
then the gaiter should be fitted nicely to the part, 
and tied. The following plan may be pursued in 
arranging and applying this apparatus, or that of 
Desault : Place upon the mattrass, and in a position 
to correspond with the fractured limb, the splint- 
cloth — a piece of muslin about two yards long, and 
as wide as the length of the inner splint, — and upon 
this arrange the strips of a bandage of Scultetus ; 
then lay the patient carefully upon the mattrass, so 
that the broken thigh, previously divested of clothing, 
shall repose upon the strips and the splint-cloth ; 
next pass the perineal band under the buttock, and 
tie the gaiter around the ankle, as before directed ; 
the limb being carefully steadied by an assistant, roll 
the splints in the cloth, commencing at the margins, leaving 
only space enough between each side of the limb t and the cor- 
responding splint, thus enveloped, to admit of the presence 
of the junk-bag, — the long pad before spoken of. (The 
proper rolling up of the splints requires some time and 




FRACTURES OF THE OS FE MORIS. 175 

trouble — they should be tightly wrapped, so that when 
pressure is used laterally upon 
the limb, they may not slip, and FlG - ' r0 - 

thus leave a larger space be- 
tween them and the leg than is 
compatible with the accomplish- 
ment of one of the objects for 
which they are employed, viz., 
the exercise of an equable and 
firm compression upon the limb, 
by the aid of the junk-bags.) 
The splints being thus prepared for use, extension and counter- 
extension should be made by assistants, the one grasping the 
foot and ankle, and the other fixing the pelvis — by one hand 
passed between the thigh and the pubis and ischium, and the 
other on the outside of the hip — while the surgeon coaptates 
the fragments, and adjusts the shape of the thigh ; he then 
arranges the bandage of Scultetus, and afterwards presses 
the junk-bags and the splints firmly against the sides of the 
limb ; the counter-extending and extending bands should now 
be tightly secured to their corresponding extremities of the 
long splint, — the tapes attached to the gaiter passing over the 
grooved margin of the block, before described. To secure 
the limb in this adjustment, three or four strips of muslin 
should be passed underneath the apparatus, at intervals along 
the limb, and tied across, the knot being made upon the edge 
of one of the splints, to prevent it slipping ; and a broad band 
should likewise confine the upper part of the long splint to 
the side. It is sometimes advisable to give additional support 
to the foot, by tying a strip of muslin around it, and then pin- 
ning the ends to the snlint-cloth. An arched frame of wire, 

Ox " 

or of hoop, should be placed over the foot, to protect it from 
the pressure of the bed-clothes. 

The limb should be placed out from the axis of the body, 
particularly in those cases where the fracture is at such a 
point as that the gluteus maximus muscle will draw the upper 
fragment of bone outwards. 

It is well to use the bandage of Scultetus during the first 
few days after the injury, since it makes gentle and equable 
pressure upon the muscles of the thigh, and assists some- 
what to keep the fragments of the bone in apposition ; after 



176 FRACTURES OF THE OS FE MORIS. 

the first week or ten days, however, it is probably as well, or 
better, to remove it, leaving the thigh exposed to the eye of 
the surgeon. 

Cold lotions should be applied at any time, as they may be 
called for by the condition of the soft parts ; anodyne lini- 
ments are sometimes of service in allaying muscular irritabi- 
lity, and in alleviating pain in the limb. 

Very excellent cures may be effected, undoubtedly, by the 
use of this apparatus ; but it is one which demands, in its 
employment, the greatest care and attention on the part of 
the attendant. There are some points to which the author 
would call particular notice: — the accidents chiefly to be 
feared, as directly connected with the use of this splint, are, 
excoriations and sloughs upon the heel, on the inner side of 
the knee, at the prominence of the inner condyle of the 
femur and the corresponding point of the tibia, and in the 
perineum. These are not necessary accompaniments of the 
mode of treatment now under consideration, and with proper 
care they will never occur ; but without great watchfulness 
they are exceedingly likely to happen ; they may be avoided 
in this way : — 

The gaiter should be unbound daily, so long as it is worn, 
and the instep, ankles, and heel carefully examined. During 
the first week, or ten days, the gaiter should be loosened 
every morning and evening, and these parts bathed with 
whiskey, or soap-liniment ; this may be done without in the 
slightest degree deranging the fragments of bone, simply by 
turning up the lower ends of the junk-bags, so as to give 
room for the introduction of the hand between the splint and 
the foot, — the strips which maintain the lateral pressure 
being securely tightened. The inner side of the knee should 
be gently rubbed in the same way, and a little indentation 
should be made in the junk-bag, corresponding with the bony 
prominences of the femur and tibia at this point. The peri- 
neal band should be loosened daily, — the limb being sup- 
ported the w T hile by an assistant, and the lateral compression 
maintained, — and the parts upon which it presses bathed, as 
the others. Whenever the apparatus is thus re-adjusted, re- 
newed extension and counter-extension should be made, and 
in order that this may be persevered in until the end of the* 
treatment, it is highly necessary that the splints shall be so 



FRACTURES OF THE OS FEMORIS. 177 

closely wrapped in the cloth, and shall approach the limb, on 
each side, so nearly, as that firm lateral pressure may be kept 
up, and thus the strain upon the foot and perineum rendered 
yery supportable. 

It is advisable, oftentimes, to vary the means by which the 
extension and counter-extension are effected. Thus, after 
having used a perineal band of the dimensions and form 
above recommended, let one be substituted flattened in shape 
and broader, so as to act upon a larger surface, and thus 
relieve that part which has been already pressed upon. So 
with regard to the gaiter, — it will occasionally, perhaps, be 
well to substitute for this a handkerchief folded into the 
cravat-shape, and applied so as to press upon the instep and 
the point of the heel, the tails passing from the sides of the 
foot, parallel with the 

axis of the limb, and FlG - 71 - 

reaching to the ex- 
tremity of the long 
splint upon which 
they are tied. (See 
fig. 71.) Another 
mode of making ex- 
tension is by means 
of adhesive plaster, 
as follows : — Cut two very long strips, of an inch, or more, 
in width, and apply them to the leg, commencing at a point 
halfway between the foot and the knee, descending spirally to 
the side of the foot, one on each side : then, when adhesion 
between the strip and the integuments has become firm, 
attach the strips to the extremity of the long splint, as by 
the other method. This plan was first employed by Dr. 
E. Wallace, of this city, while Resident Surgeon at the Hos- 
pital ; he used it as a substitute for the gaiter, which had 
produced excoriation just above the heel; the author had the 
pleasure of witnessing the complete success which attended 
the operation of this novel extending band, both in the in- 
stance in which it was first tried and in several other cases, 
and he would recommend it highly, as being perfectly secure 
and efficacious. It may be proper to make use of a few turns 
of a roller, or of a bandage of Scultetus, to compress the 
adhesive strips against the leg, but this is scarcely called for, 




178 FRACTURES OF THE OS FE MORIS. 

since the junk-bags exercise sufficient pressure of them- 
selves. 1 

If there is any disposition to excoriation or sloughing upon 
the points of the malleoli, pressure should be taken ofi* from 
them, by not allowing the junk-bags to extend so low down. 
The same accident may be prevented from occurring upon 
the point of the heel by placing a cushion just above it, 
under the leg, so that the weight of the limb shall not fall 
upon this point. The same simple method may be resorted 
to when a similar accident threatens the hips or back, — a 
judicious arrangement of pillows will often obviate much mis- 
chief, aided also by stimulating liniments applied to the parts. 
When, in spite of these precautions, sloughing does occur — 
as it sometimes will in old persons, or in those of lax fibre, — 
all pressure should be at once withdrawn from the affected 
surface, and the separation of the dead tissue aided by the 
application of poultices ; afterwards stimulating washes 
should be used, among the best of which is Labarraque's 
solution of the chloride of soda, diluted with three or four 
parts of water, and applied to the ulcer upon rags, or, if the 
slough has extended beneath the skin, injected from a 
syringe. 

There is one objection to the employment of this apparatus 
of Desault and Physick in the treatment of fractures of the 
thigh, occurring particularly in the upper third of the shaft 
— (and the same objection is applicable to the treatment by 
extension in the straight position, generally) : it is sometimes 
impossible to counteract, by it, the deformity which arises 
from the powerful contraction of the iliacus internus and psoas 
magnus muscles, which tilt up the lower end of the upper 

1 I am greatly indebted to the kindness of Dr. Gross, the distinguished 
professor of surgery at Louisville, for the knowledge of the fact that this 
application of adhesive plaster was originally made more than twenty years 
ago, by Dr. Swift, of Easton. 

In his treatise on " the Anatomy, Physiology, and Diseases of the Bones 
and Joints" (Philadelphia, 1830, p. 50), Dr. Gross points out the reasons 
which led Dr. Swift to suggest this means of making extension ; they are 
precisely those which induced Dr. Wallace to resort to this expedient. Dr. 
Wallace, I am sure, had no knowledge that any one had previously recom- 
mended or employed the adhesive plaster for this purpose. 

Latterly, the employment of adhesive strips has been very much extended 
to the treatment of many other fractures ; as by Dr. Crosby, to fracture of 
the clavicle. (New York Journal of Medicine, 1851.) 



FRACTURES OF THE OS FE MORIS. 179 

fragment. When this action is but slight it may be over- 
come, gradually, by compression with a splint bound upon the 
anterior face of the thigh, or by a compress, or, finally, by a 
little elevation given to the lower fragment by means of a 
folded sheet placed beneath the thigh, at this point. But in 
very athletic patients the muscles in question may contract 
too powerfully, and then these means will fail ; if the straight 
splints are retained, a permanent deformity will ensue and 
the limb will be always weak, in consequence of the imper- 
fect apposition of the fragments. In such cases as these, the 
double inclined plane should be substituted for the other 
apparatus. 

The apparatus of Desault, improved as above described, is, 
we think, the best which has yet been contrived for the treat- 
ment of fractures of the thigh, in the extended position. 

There are several other modifications of Desault's appara- 
tus, less simple than the one which we have explained. 

The late Dr. Hartshorne, of this city, invented one in 
which the long and the short splints are connected together 
by a transverse piece, through which a long wooden screw 
passes, having a foot-board attached to it. 

Dr. T. H. Bache, lately resident Surgeon to the Pennsyl- 
vania Hospital, has modified Physick's apparatus as follows : 
A long, narrow fenestrum is cut in the outer splint, extend- 
ing upwards from near its lower extremity ; in this slides 
an iron arm, capable of being firmly fixed by screw-clamps at 
any point, so as virtually to lengthen or shorten the splint in 
adaptation to limbs of different length; through this arm 
passes a long screw, its axis being continuous with that of the 
limb when placed between the two splints, and to the upper 
or proximal end of the screw is attached a transverse piece 
of iron, having a hole pierced through each extremity. To 
apply this apparatus, the limb is placed between the two 
splints, and a counter-extending band and junk-bags are 
arranged just as in Physick's method ; but the extending tapes 
or adhesive strips are secured to the transverse iron plate 
last spoken of, so that the elongation of the limb is accom- 
plished by acting upon the screw which passes through the 
arm that is connected to the outer splint. The arrangement 
is very neat, and the apparatus light and strong. Its action 
is very well spoken of by the gentlemen who are attached to 



180 FRACTURES OF THE OS FE MORIS. 

the Pennsylvania Hospital; it is believed by them that it 
effects elongation of the shortened limb more gradually than 
Physick's splint, and that it enables the surgeon to judge 
accurately whether or not he is really gaining in this 
particular. 

I must confess that I should prefer the simpler apparatus 
of Dr. Physick. From having seen Dr. Bache's splint in use 
at the Hospital in two or three cases of fractured thigh, my 
impression is that the foot is not as securely and steadily held 
by this as by the other ; and it appears to me that to make 
extension by the screw, rather than by the hands directly ap- 
plied to the limb, is more likely to endanger excoriation of 
the foot. The stretching of the extending strips or tapes, 
under the force constantly acting upon them, will readily de- 
ceive any one who trusts to the mere operation of the screw 
to inform him as to the improvement in the length of the 
limb. Moreover, the simplicity of Physick's apparatus is in 
itself an advantage and a recommendation. Perhaps the 
splint of Dr. Bache might be improved by attaching to the 
screw a foot-piece, to which the foot should be immediately 
secured, instead of having a simple transverse piece. 

Boyer's apparatus is composed of a long splint for the ex- 
ternal side of the limb, with a movable foot-board connected 
therewith ; of two straight splints for the anterior and inner 
faces of the limb ; a belt enclosing the upper part of the 
thigh and the groin, and giving a "point d'appui" to the 
upper extremity of the outer splint ; straps to secure the foot 
to the foot-board ; cushions, and tapes to confine the appara- 
tus upon the limb. The outer splint is the only complicated 
part of the apparatus. It is about four feet long and as 
many inches in width ; from its lower extremity upwards, 
along about half its length, runs a groove in which a screw 
plays ; the upper end of the screw turns upon an iron plate, 
while the other extremity, at the end of the splint, has a key 
attached to it, by which it is made to revolve. A foot-piece, 
made of iron, and padded, is connected with the screw, upon 
the inner side of the splint, and is moved nearer to, or far- 
ther from, the lower extremity of the latter by revolutions 
of the screw, so as to make the necessary extension, while 
the upper end of the splint fits into a little pouch upon the 
thigh-strap, thus effecting the counter-extension : the foot- 



FRACTURES OF THE OS FE MORIS. 



181 



piece has two legs upon which it rests. In the application 
of this apparatus the foot is attached to the iron plate ; the 
upper end of the splint is inserted into the pocket of the 
thigh-belt, which has been previously passed around the 
upper part of the thigh and groin ; a long pad protects the 
limb from contact with the outer splint, and equalizes the 
pressure from it ; then, after the reduction of the fracture, 
the inner and anterior splints, well padded, are placed upon 
the thigh, and the whole is secured by means of several 
bands, as shown in the figure. (See fig. 72.) As much ex- 
tension as the surgeon thinks necessary is made by turning 
the screw, thus drawing down the foot, and with it, of course, 
the lower fragment of the broken femur. 

Fig. 72. 




Mr. Liston recommends the employment of a single 
straight splint of deal-board, long enough to extend from 
opposite the nipple to three or four inches beyond the foot ; 
near its upper end two holes are bored, and the lower extre- 
mity is notched, while just above the latter is a perforation 
large enough to accommodate the malleolus ; the splint is co- 
vered on its inner face by a cushion. The leg is bandaged 

Fig. 73. 




from the toes nearly to the seat of fracture, before the splint 
is applied: then the fracture is reduced, and the perineal 
16 



182 



FRACTURES OF THE OS FE MORIS. 



Fig. 74. 



band — made as for Desault's apparatus — is tied to the upper 
end of the splint, to which the whole limb and the side of the 
body are now confined by means of a roller, — several turns 
being passed around the foot, and gaining support from the 
notches made in the lower end of the splint. (Liston's Pract. 
Surg.) (See fig. 73.) 

Drs. Kimball and Sanborn, of Lowell, Mass., have contrived 
a single splint for the treatment of fractures 
of the thigh, which is figured in Miller's Prac- 
tice of Surgery. (Fig. 74.) 

It extends from the axilla to below the foot, 
but is so contrived as to be capable of being 
lengthened at each extremity. The upper end 
terminates in the manner of a crutch ; the 
lower has a sliding bar fitted to it, upon which 
a transverse arm is secured at right-angles. 
In using this splint, " two long pieces of strong 
adhesive strap are applied, one on each side 
of the limb, extending from above the knee to 
the ankle, and these are secured by a roller. 
The end of each strap is uncovered with adhe- 
sive matter, and hangs loose from the foot. 
The ends of each strap are secured to the 
cross-bar at the splint's extremity, and the 
limb is made one with the splint in the ordi- 
nary way. By turning the screw, the cross- 
bar is moved up or down, at will, and extension 
consequently is regulated with both accuracy 
and power. The perineal band is employed 
besides, but should its pressure prove at any 
time galling, it may be temporarily discon- 
tinued with safety, the crutch of the splint 
being moved up into the axilla, to supply its 
place." (Miller's Practice, p. 652.) 

We do not see that the screw-extension 
power is of much advantage, and we can by 
no means advise any one to dispense with the 
perineal counter-extending band, because the 
axilla does not offer a fixed point of resistance. 
And, moreover, it is impossible to preserve the proper shape 
and direction of the limb if only one splint is used. 




FRACTURES OF THE OS FE MORIS. 



183 



The same objection is applicable to the original splint of 
Hagedorn, which consists of a single long splint and a foot- 
board, the latter being broad enough to support both feet, 
and moving up and down, but capable of being secured at any 
point upon the splint. 

Dr. Gibson, Professor of Surgery in the University of 
Pennsylvania, has introduced a modification of Hagedorn's 
apparatus, which he thus describes — (" Institutes and Prac- 
tice of Surgery," vol. i.): — " This method consists in extend- 
ing the patient's limbs upon a mattrass, and confining both 
feet, by gaiters, or a handkerchief, to a footboard which is 
firmly supported upon the ends of two splints passed through 
mortices near its edges. These splints extend from the arm- 
pit, where they are padded like the head of a crutch, along 
each side of the body, thigh and leg, beyond the foot, and, 
being well stuffed on their inner surfaces to prevent irritation, 
are confined by six or eight 'broad tapes or bandages passed 
around the limbs, pelvis, chest, &c. (See fig. 75.) 

." The principle upon which extension and counter-extension 
are effected by this contrivance, will instantly be understood. 
The sound limb being extended, serves as a splint to the bro- 

Fig. 75. 




*i(f?Tw 



ken one. Counter-extension then is made upon the acetabu- 
lum of the sound side, and extension upon the ankle of the 
injured limb, which, so long as the two feet are kept on the 
same level, cannot be shortened, provided rotation of the 
pelvis be prevented. This purpose is answered by extending 
the splints to the arm-pits, and not with a view, as might be 
supposed, of producing counter-extension from these points. 
Finding that the patient, in the original machine of Hage- 
dorn, could incline the pelvis towards the affected side, and 



184 FRACTURES OF THE OS FE MORIS. 

thereby shorten the limb, by causing the superior fragment 
to descend and overlap the inferior, the additional splint 
was added, and has been found to answer completely the end 
designed/' 

During my residence in the Pennsylvania Hospital, I had 
the opportunity of testing the efficacy of this apparatus, in 
two cases of fracture of the thigh, — one in a child, the other 
in an adult. In both instances, the result was as satisfactory 
as I have ever seen to follow the employment of any other 
method : I was led to make use of this apparatus, because the 
skin about the ankle and perineum of the child was so very 
tender, as to render the pressure upon these parts, from the 
gaiter and counter-extending band of Desauit's apparatus, 
insupportable, and, moreover, he was not sufficiently restrained 
by this last-mentioned apparatus; — and because, in the in- 
stance of the man, the whole instep was much bruised by the 
same fall which caused the fraclure of the thigh. The plan 
which I adopted was the following : — A straight splint was 
first confined to the under surface of the sound limb, to pre- 
vent flexion of the knee ; the splints were then placed on 
each side of the patient ; the sound foot was secured to the 
foot-board ; long pads protected the outer sides of the limbs 
from contact with the boards ; the fractured thigh was brought 
to the same length as the other, and the foot bandaged to 
the foot-board; a firm junk-bag was now inserted between the 
limbs along their whole length, so that the injured limb should 
be supported at every point by the other, and several wide 
strips of muslin were made to enclose in their grasp each 
thigh, with its splint and the junk-bag; finally, the splints 
above the pelvis were pressed against the patient's sides, by 
means of muslin bands, and in the same manner lateral 
pressure was effected upon the whole apparatus. 

The management of this apparatus requires great atten- 
tion ; its confinement is very irksome to the patient, as it 
imprisons both limbs. It is particularly troublesome, when 
he has an evacuation of the bowels to effect, because he can- 
not assist himself, nor the attendant, with the sound leg ; 
when it is employed, therefore, a clinical frame, such as has 
been described, should be used instead of an ordinary frac- 
ture-bed, or the fracture-bed herein described, will be found 
serviceable and convenient. 



FRACTURES OF THE OS FEMORIS. 185 

The same care as when the other splints are resorted to, 
is requisite, with regard to the prevention of injury to the 
parts of the integuments pressed upon, as the heel, ankles, 
hips, &c. 

It is proper to mention that, in the man upon whom this 
apparatus of Dr. Gibson was tried, the fracture was at the 
lower third of the femur, and that the thigh was not a very 
muscular one. "Whether a sufficient degree of extension can 
be accomplished by it, to maintain in coaptation the frag- 
ments of a thigh-bone, when the muscles of the limb are fully 
developed, and when the fracture is higher up, within the 
operation of the glutaeus muscle, the author cannot affirm ; he 
has a sufficiently good opinion of the apparatus, however, to 
be induced to use it again. 

In fractures of the shaft occurring in young children, the 
method recommended by Mr. Liston, as before described, 
with the addition of curved splints for the anterior, posterior, 
and inner surfaces of the thigh, is the most convenient and 
the best plan of treatment. The naturally slightly curved 
shape of the bone should be recollected, and this conforma- 
tion should be secured by the proper use of compresses. 

2. For fractures of the thigh at its upper extremity. 

The general principles of treatment in these cases are the 
same as when the shaft is broken ; but there are so ae ana- 
tomical and physiological peculiarities of the pelvic extremity 
of the os femoris, which require corresponding modifications 
of treatment, when this part of the bone is ruptured. 

When the fracture occurs within the capsular ligament of 
the joint, bony union, according to the best authorities, is at 
least exceedingly improbable, though not impossible. (See 
Sir A. Cooper, Cruvelhier, R. W. Smith, &c.) The acci- 
dent happens, moreover, for the most part, to persons ad- 
vanced in life and incapable of supporting long confinement 
in bed in any one position. Concerning the treatment of 
these cases, Sir A. Cooper makes the following remarks : — 
" I would prefer a ligamentous union to the confinement and 
danger of bony union, in regard to the health and life of the 
person, and, as I believe, to the subsequent use of the joint. 
Baffled in our various attempts to cure these cases, and find- 
ing the life of the patient occasionally sacrificed under the 
trials made to procure bony union, I should, if I sustained 
16* 



186 FRACTURES OF THE OS FE MORIS. 

this accident in my own person, direct that a pillow should be 
placed under the limb throughout its length ; that another 
should be rolled up under the knee, and that the limb should 
be thus extended until the inflammation and pain had sub- 
sided. I should then daily rise and sit in a high chair, to 
prevent a degree of flexion which would be painful ; and, 
walking with crutches, bear gently on the foot at first, then, 
gradually more and more, until the ligament of union had 
become thickened, and the muscles increased in their power. 
A high-heeled shoe should be next worn, by which the halt 
would be much diminished. Our hospital patients, treated 
after this manner, are allowed in a few w T eeks to walk with 
crutches ; after a time a stick is substituted, and in a few 
. months they are able to use the limb without any adventitious 
support." (Sir A. Cooper, op. cit., p. 142.) 

When the solution of continuity has occurred partly within 
and partly without the capsular ligament, or through the 
great trochanter, the displacement is less, and it is more 
easily obviated. The limb should be kept in the extended 
position, by any of the methods which have been described, 
and the outer splint should be pretty firmly pressed against 
the trochanter and the side of the body by a circular band- 
age. The apparatus of Dr. Gibson would answer admirably 
in these cases. 

If the trochanter major be merely severed from the root 
of the neck, the axis of the bone not being involved, there is 
no shortening of the limb, and the treatment of the accident 
is very simple. The patient should be kept upon his back, 
with the limb in the extended position, and rendered in- 
capable of flexion at the knee and thigh by means of a well- 
padded splint, extending from above the tuberosity of the 
ischium to near the heel, and secured thus by rollers ; in 
addition, a broad band should be passed around the pelvis, to 
compress the fragment of the trochanter upon its place. 

The annexed wood-cut illustrates a method pursued by Sir 
A. Cooper, in the treatment of this injury. The patient is 
lying upon a fracture-mattrass, to the foot of which is attached 
an upright support for the sole of the foot ; a broad band 
grasps the trochanter and presses it upon its natural seat. 
(See fig. 76.) 

3. For fractures at the lower extremity of the femur. 



FRACTURES OF THE 08 FEMORI: 
Fig. 76 



187 




I'llllII llllll II li"" I 



The thigh-bone may be broken transversely just above the 
condyles, or obliquely, or the fracture may extend through 
the condyloid expansion into the joint. 

In the first case, there is oftentimes no displacement, or if 
the axis of the limb has been deranged, the fragments, after 
reduction, are easily retained in apposition by lateral com- 
pression and rest in the extended position. 

When, however, the fracture extends obliquely from behind 
forwards and downwards, as is usually its line of direction, or 
even from before backwards and downwards, the powerful mus- 
cles which descend from the pelvis act with great energy upon 
the lower fragment, and draw it upwards, leaving the ex- 
tremity of the upper fragment, in the first-mentioned variety, 
projecting anteriorly and penetrating the rectus muscle, 
sometimes perforating the integuments even. The treatment 
of this injury consists in keeping up strong extension and 
counter-extension in the straight position, and in making as 
firm compression upon the fragments, when reduced, as the 
condition of the parts will allow, aided generally by evapora- 
ting lotions, leeching, &c, &c. After the lapse of three or 
four weeks, passive motion should be commenced cautiously 
and persisted in. (Sir A. Cooper.) 

Others advise that the limb should be secured upon the 
double inclined plane, the foot being well supported. They 
urge in favour of this position, that it relaxes the muscles 
which act so powerfully upon the lower fragment, and thus 
renders sufficient a less degree of extension upon the inflamed 
joint, while the mere pressure of the under surface of the 
limb upon the plane counteracts in a great measure the 
retraction of the lower fragment. 



188 FRACTURES OF THE OS FEMORIS. 

A strong argument in favour of the straight position is 
that, if anchylosis should occur, the limb is in a much 
more desirable position than if the double inclined plane is 
employed. 

When one of the condyles is separated from its connexion 
with the lower portion of the femur, the extended position is 
certainly the most favourable one for the relief of the acci- 
dent. A piece of pasteboard, large enough to inclose the 
posterior two-thirds of the joint, and notched along its mar- 
gins to enable it to adapt itself better to the form of the part, 
should be softened in hot water and then moulded about the 
posterior face of the knee, and secured thus by means of a 
roller ; Desault's apparatus, or a single straight splint for the 
under surface of the limb, will complete the necessary con- 
fining means. 

4. For compound fractures of the thigh, the same general 
principles of treatment exist as for the simple : the accident 
should be converted into a simple fracture, if practicable, by 
immediate closure of the wound ; and during the whole pro- 
gress of the case, the natural conformation and length of the 
limb should be preserved, as far as possible. It must be 
borne in mind, however, that some degree of shortening will 
occur almost of necessity, in consequence of necrosis of the 
broken extremities of the bone, and because, from the nature 
of the injury, the same degree of extension and of lateral 
compression cannot be maintained as in cases of simple 
fracture. 

The limb may be placed in the flexed position on a double 
inclined plane, or it may be extended by means of any of the 
different sorts of apparatus already described, or, finally, it 
may be placed in a long fracture-box, the sides of which are 
connected by hinges with the bottom piece, and extend, on 
the outer side to the axilla, and on the inner to trj.e pelvis, 
the foot being secured to a perpendicular plane attached to 
the lower extremity of the bottom-piece. In this box, the 
limb may repose upon a bed of bran, which also affords the 
necessary lateral pressure when the sides of the box are 
closed. Probably, if the fracture be seated in the vicinity 
of the middle of the bone, it can be treated as well in Phy- 
sick's apparatus as in any other. Either of the splints can 
be bracketted opposite the point of injury, as is represented 



FRACTURES OF THE OS FE MORIS. 



189 



in the accompanying drawing from Mr. Erichsen's Treatise, 
in which Mr. Liston's splint is thus arranged. (Fig. 77.) 



Fig. 77. 




The bandage of Scultetus is, as in other compound frac- 
tures, the best compressing bandage, as it admits of removal 
and adjustment without disturbing the limb. The wound 
itself should be uncovered, excepting by a poultice, or some 
similar dressing, so that the matter may have free escape, 
and this should be aided by moderate pressure upon the thigh, 
above and below the wound, effected by the bandage, which 
should be made to act with particular care on any point or 
points beneath which the matter may be disposed to collect : 
if an abscess should form at any point remote from the wound, 
as happens in almost every compound fracture, it should be 
opened by the knife. 

The dressing for the wound must be varied to suit its ap- 
pearance at different times. Great cleanliness of the parts, 
and also of the dressings, should be observed. 

The great length of time during which it is necessary to 
confine the patient to bed renders it advisable to resort to 
every expedient to prevent sloughing ; besides the frictions 
heretofore recommended in compound fractures, the position 
of the patient should be changed, from time to time, as far as 
may be consistent with the security of the limb ; the use of the 
inclined plane, for example, may be alternated with that of 
the straight splints. 

When the condition of the wound will allow of more direct 
compression being exercised about the seat of fracture, this 
means should be instituted as an aid in securing a proper shape 
to the thigh. For this purpose, strips of adhesive piaster, or 
of soap plaster, may be employed, — while the roller, or the 



190 FRACTURES OF THE PATELLA. 

bandage of Scultetus, cannot be used, — an interval being left 
between the strips, for the ready escape of the pus. 



SECTION II. 

ON THE APPARATUS AND DRESSINGS FOR FRACTURES OF THE 

PATELLA. 

The patella may be broken longitudinally, or transversely. 

1. Longitudinal fractures of this bone are attended with 
little or no displacement of the fragments, as a general rule ; 
hence the probability of perfect reunion by bony matter is 
great, and the treatment is very simple. The leg should be 
extended upon the thigh, and the thigh flexed to a moderate 
degree upon the pelvis, while a roller is passed around the 
limb, from the toes to the upper part of the thigh, being made 
to exercise considerable lateral pressure upon the fragments 
of the patella, by means of compresses placed at each side of 
the bone. The limb should be laid on a simple inclined plane, 
and, for the sake of greater security, a splint should be bound 
to its under surface. The application of these retentive means 
should be preceded, if there be much inflammation about the 
joint, by leeching; and after the bandage is applied, cold lo- 
tions may be employed, if required. 

2. When the fracture has assumed a transverse direction, 
a considerable degree of separation of the fragments is una- 
voidable, the retraction of the upper portion varying from one 
to three or four inches, according to the power of the exten- 
sor muscles which are connected with the base of the patella, 
and to the position in which the limb has remained after the 
injury. 

A variety of mechanical contrivances have been resorted to, 
to remedy the effects of this accident and to maintain the frag- 
ments in apposition. The bond of union is usually ligamen- 
tous, so commonly that Pibrac offered a prize of one hundred 
louis d'or to any one who would show him a specimen of trans- 
verse fracture of the patella cured by bony union. Specimens 
of this mode of healing do, however, exist. But it must be 
borne in mind by the surgeon that, although a very good ap- 



FRACTURES OF THE PATELLA. 



191 



position may have been gained and retained during the treat- 
ment, the ligament of union almost invariably becomes elon- 
gated after the patient commences to use the limb, even when 
a splint has been bandaged to its under surface and worn thus 
for a long time after confinement to bed has ceased. This fact 
should always be impressed upon the patient and his friends, 
as otherwise the surgeon may suffer in reputation. 

The treatment recommended by Sir A. Cooper is, that the 
limb be lightly bandaged to a straight splint placed all along 
the under surface of the limb, the knee being left entirely un- 
covered ; that the extensor muscles of the leg be relaxed by 
elevating the limb upon an inclined plane, while the trunk is 
flexed upon the pelvis, and that local antiphlogistic remedies 
be applied upon the joint, until inflammation shall have ceased. 
Then " a roller is applied from the foot to the knee, to pre- 
vent the swelling of the leg, and the upper portion of the pa- 
tella is pressed downwards towards the lower, as far as it can 
be without violence, so as to produce the approximation of the 
fragments. Rollers are applied above and below the joint, 
confining a piece of broad tape next the skin on each side, 
which crosses the rollers at right angles ; these tapes are next 
bent down and tied over the rollers, so as to bring the latter 
near to each other, and thus to keep down the upper portion 
of bone. Sometimes, instead of the tape on each side, a broad 
piece of linen is bent over the rollers on the fore part of the 
joint, and is there confined, so as to approximate the portions 
of bone and to bind down the upper fragment of the patella, 
that its lower broken edge may not turn forwards." (Op. cit. 
p. 205.) (See fig. 78.) 

Fig. 78. 




Another method recommended by the same high authority 



192 



FRACTURES OF THE PATELLA. 



is the following : — A leathern strap may be buckled around 
the lower part of the thigh, above the broken and retracted 
fragment of bone ; from this circular band another strap should 
be passed along the side of the leg across the sole of the foot, 
the leg being extended and the foot flexed as much as possible. 
This strap is then carried up along the other side of the leg, 
and buckled to that which has been fixed around the thigh ; 
it may be confined to the foot by a tape tied to it, and to the 
leg, at any part, in the same manner. This is a very conve- 
nient bandage for the fractured patella, and for the patella 
dislocated upwards by the laceration of its ligament. A roller 
is to be applied around the leg. (Op. cit. p. 205.) (See fig. 79.) 

Fig. 79. 




M. Desault directed that the limb should be held in the po- 
sition above advised, by an assistant, and a roller passed 
around the leg from the toes to the knee, confining on the 
front of the leg a band about two inches wide and of the 
length of the limb ; then that two longitudinal slits be made 
in this band, opposite the patella, through which the surgeon 
passes tw T o fingers and approximates the fragments : that a 
compress be applied just above the upper fragment and re- 
tained there by several turns of the roller passing around the 
knee in the form of the figure 8 ; the bandage now should cover 
the thigh, a padded splint, as long as the limb, should be con- 
fined upon its under surface, and the whole supported on an 
inclined plane. 

M. Gerdy employs an invaginated bandage, such as is used 
in the approximation of the lips of transverse wounds. (See 
chap, on Wounds.) The leg, as high as the knee, is enveloped 
by a roller, which also confines upon the front of the leg the 
tailed portion of the bandage, the slit portion being secured 
upon the front of the thigh by a second roller ; then, having 



FRACTURES OF THE PATELLA. 



193 



placed a compress above the upper fragment, and another "be- 
low the inferior, pass the tails of the bandage through the 
slits, and approximate the fragments ; this having been effected, 
lay the portions of the bandage smoothly along the limb, and 
secure them by turns of a roller. 

Mr. Amesbury has invented an apparatus consisting of 
two wide leathern pads, to be placed one on the anterior face 
of the thigh above the knee, the other on the leg below the 
knee, and attached to each other by straps and buckles. In 
order to compress the extensor muscles of the leg, and at the 
same time to avoid unnecessary constriction of the limb, 
these pads are secured by means of straps and buckles, to a 
splint placed on the under surface of the member, with a 
foot-board attached, and made sufficiently wide, opposite the 
knee, to project a little beyond it upon each side. The upper 
pad, and with it the corresponding fragment of the patella, 
is made to approximate the lower by means of a strap, which 
passes from the lower edge of the upper pad, along the side 
of the leg, and across the foot-board, to ascend on the other 
side of the leg and be buckled to the pad. (Amesbury, vol. 
ii. p. 492, &c.) 

Mr. Lonsdale has contrived an instrument, which he has 
found very efficacious in the treatment of this fracture. It 
consists of a splint upon which the limb reposes, and to which 
a foot-piece is attached in such a way as to be movable up 
and dow T n, to accommodate the splint to limbs of different 
lengths ; to the under surface of this splint two vertical iron 
bars are connected, AB, (see fig. 80,) at about its centre, 
each one supporting a horizontal arm bent at right angles, 
G G ; these horizontal pieces slide upon the upright staffs, but 

Fig. 80. 




194 FRACTURES OF THE PATELLA. 

can be arrested at any point by the screws, C D ; from these 
arms depend other vertical rods, movable upon the former, 
and, like them, fixable by similar screws, E ; finally, to the 
lower end of each of these second perpendicular rods, an iron 
plate, F, F, of a horse-shoe form, is attached, by means of a 
hinge-joint. In the application of this apparatus, the splint 
should be well padded, and the foot and leg secured to it by 
a roller, a bandage having been first passed around these 
parts ; then the surgeon places the fragments of the patella 
in juxtaposition, the muscles being relaxed as before directed, 
and applies the upper horse-shoe plate to the upper part of 
the thigh, a soft pad intervening, just above the superior 
fragment, — not touching the patella itself, while the other 
plate is applied just below the inferior fragment ; the plates 
are secured in these relations by means of the screws, and a 
roller is passed around the thigh and the upper part of the 
splint. The limb is retained during the treatment in the 
same position as in the other modes already described. 

Mr. Lonsdale states the advantages of this apparatus to be, 
that it may be applied immediately after the fracture occurs, 
that it produces no constriction of the limb, and that it 
leaves the injured part exposed to the inspection of the sur- 
geon during the w 7 hole course of the treatment, and allows of 
the application of antiphlogistic remedies ; he has found it to 
answ 7 er the purpose for which it was intended, in a very satis- 
factory degree. (Op. cit., p. 427, &c.) 
, Mr. Fergusson describes a very simple and neat apparatus, 
contrived by Mr. John Wood, for the treatment of this injury. 
It consists of a splint extending from the pelvis to the sole 
of the foot, hollowed to receive the limb, and a foot-piece 
attached ; the lower extremity of the splint rests upon 
block, so that when applied, the plane upon which the member 
reposes, is inclined. The limb is confined upon the splint by 
means of rollers, the fragments of the patella being retained 
in apposition by a few turns after the manner of the figure 8, 
and to prevent these latter turns of the roller from slipping, 
two hooks are screwed into each side of the splint, above and 
below the position of the knee, around which the bandage 
passes. (Fig. 81.) 

The apparatus of Boyer, of Dorsey, Mogridge, and others, 



FRACTURES OF THE PATELLA. 195 
Fig. 81. 




offer no particular advantages above those which have been 
described. 

M. Malgaigne, in his excellent " Traite des Fractures, p. 
764, states, that he has seen M. Gama, surgeon to the mili- 
tary hospital of Val de Grace, treat successfully cases of 
transverse fracture of the patella, by means of strips of adhe- 
sive plaster passed above and below the fracture, in the form 
of the figure 8, the limb being placed upon the simple in- 
clined plane. And in the Philadelphia Medical Examiner, 
p. 5, Jan., 1854, Dr. John Neill reports two cases of this 
injury in which this method was pursued. It is, undoubtedly, 
the simplest and the best plan which can be resorted to. 

After the limb has been thus confined for six or eight 
weeks, passive motion should be commenced and practised 
cautiously but diligently ; in the course of two weeks' longer 
time, the patient may be permitted to bear moderately upon 
the foot in walking, a splint being bound to the under surface 
of the limb ; he should step on the sole of the foot flatly, 
and not on the toe ; the splint should be worn thus, for a few 
weeks. 

3. Rupture of the tendon, and of the ligament of the 
patella should be treated in the same manner as if the bone 
itself were broken. 

4. Compound fractures of the patella require the same 
general principles of treatment as the simple forms. But in 
addition to the injury done to the bone, that which is inflicted 
upon the soft parts and on the joint demands attention, and 
modifies the treatment. The indications are, to close the 

ound immediately, in the hope that it will heal without being 
accompanied by violent constitutional disturbance, and to 



196 FRACTURES OF THE PATELLA. 

retain the fragments of the patella in as close apposition as 
the condition of the parts will permit. The limb must be 
placed upon a splint in the same position as directed for 
simple fracture, the body being well supported in the flexec 
position on the pelvis, by pillows arranged behind the back. 
The lips of the wound, after all foreign matter has been 
removed from the opened joint, should be drawn together by 
strips of adhesive plaster, which strips may be so applied as 
to draw down the upper fragment of the patella, and to retain 
it in apposition with the lower : then a piece of lint shoulc 
be dipped in the blood which flows from the part, or in some 
adhesive and glutinous fluid, and laid upon the wound, where 
it should be retained by a light bandage ; all pressure being 
avoided upon the joint itself, the muscles of the thigh may 
be moderately compressed by a roller, the same which con- 
fines the splint upon the limb. Thus arranged, the dressing 
should not be disturbed so long as no unpleasant symptom 
arises ; such as severe inflammation, free suppuration, &c. 
In a case recorded by Sir A. Cooper (op. cit., p. 210, 11), 
the first applications were not removed until a month after 
the accident, when the wound was found nearly healed ; the 
patient in this case recovered with a perfectly useful limb. 

The author treated in this manner, at the hospital, a case 
of compound fracture of the patella, produced by a kick from 
a horse, in which a similarly happy cure followed. If, how- 
ever, violent inflammation follows the injury, with profuse 
discharge and much constitutional suffering, the primary 
dressing must be at once removed, and antiphlogistic reme- 
dies resorted to, — as local and general depletion, poultices, 
or water-dressings, &c, &c. Passive motion should be cau- 
tiously instituted as soon as circumstances will admit of it. 
The introduction of sutures should be avoided as much as 
possible ; if employed, care should be exercised not to include 
the ligament in the suture. (Sir A. Cooper, op. cit., case 137, 
p. 210.) 



FRACTURES OF THE BOXES OF THE LEG. 197 



SECTION III. 
FOR FRACTURES OF THE BONES OF THE LEG. 

Like those of the fore-arm, the two bones of the leg may- 
be broken at the same time, or each may be fractured sepa- 
rately. 

1. When both the tibia and fibula are broken, the maximum 
degree of displacement is produced, partly by the violence 
causing the fracture, and partly by the action of the powerful 
muscles situated about the leg. The line of fracture is gene- 
rally oblique, in almost any direction, and this direction influ- 
ences the course of displacement which the lower fragment 
assumes. When the solution of continuity of the fibres of the 
bone is in a transverse direction, there is often no shortening 
of the leg, but merely a lateral derangement ; when, however, 
the fracture is oblique, there is both lateral deformity and 
shortening ; in the former injury, the fragments are easily 
retained in apposition, after reduction, by rest alone ; in the 
latter, a continued confining apparatus is necessary to coun- 
teract the disposition on the part of the muscles to contract 
and to draw upwards the inferior portion of the bones. Gene- 
rally, a moderate degree of mechanical force, with the limb 
in the straight position, suffices for the successful treatment 
of simple fractures of the leg ; there are instances, however, 
in which, from the powerful action of the muscles and the 
direction of the line of fracture, such deformity is produced 
that it becomes desirable to take advantage of the effect of 
position to aid the treatment, as in fractures of the thigh. 

The simplest plan of treatment by mechanical means, con- 
sists in the employment of the " junks ;" — these are generally 
made of pieces of wood, or of bags of straw, or chaff, rolled 
firmly in a splint cloth, and long enough to extend from the 
lower third of the thigh to below the ankle, on each side of 
the limb. In the application of this apparatus, the junks 
thus rolled are glided underneath the leg upon a pillow, which 
supports the whole leg and the heel ; the fracture is reduced, 
and the mechanical supports brought in contact on each side 
with the knee and the ankle, all the intermediate parts of the 
leg being likewise apposed to the lateral supports, either 
17* 



198 FRACTURES OF THE 

directly, or through the intervention of compresses of cotton, 
or tow ; the whole is secured thus by strips of muslin passed 
around the junks. 

This apparatus leaves the anterior face of the leg exposed 
to the examination of the surgeon and to the action of local 
applications, while at the same time it exerts a sufficiently 
powerful lateral compression upon the leg, to retain in appo- 
sition the fragments of the bones, in all cases of transverse 
fracture, and in many, or most, of the oblique. It does not, 
however, offer so great a degree of security against sudden, 
or accidental, movements of the limb, as another apparatus, 
which is almost as simple as itself, — the fracture-box, of which 
mention will be made directly. 

Many different kinds of splints have been contrived at 
various times, and by different surgeons, for the treatment 
of these injuries. The best have all sought to give support 
to the inferior surface of the leg and the foot, and also to 
exert more or less lateral compression. Thus the splints of 
Mr. Neville, highly recommended by Mr. Lonsdale and others, 
consist of a light iron piece padded, for the inferior face of 
the leg, extending from the lower part of the thigh to the 
foot, at which point it curves upwards, to form a support for 
the sole of the latter, — and of two lateral splints, of the same 
length as the other, and also padded, and secured to the sides 
of the foot-piece by a mortice-and-pinion joint ; circular strips 
of muslin complete the apparatus. 

The fracture-box, however, combines all the advantages of 
these with many others which these do not possess, as greater 
simplicity of construction, and in consisting of but a single 
piece, as it were, by which greater solidity is gained. It is 
composed of a horizontal plane of board extending from a 
little above the knee to the sole of the foot, where a piece, 
rather longer than the foot, and of the same width as the 
other plane, is firmly secured to it at right angles : side- 
pieces, also made of wood, six or seven inches wide, and of 
the same length as the bottom-piece, are connected with the 
latter by hinges. (Fig. 82.) To apply this apparatus to the 
treatment of fractures of the leg, open the sides of the box, 
and place a pillow upon it, soft enough to adapt itself well to 
the inequalities of the leg ; then, having reduced the fracture, 
secure the foot to the foot-board by a strip of bandage, and 



BONES OF THE LEG. 



199 



Fig. 82. 



close the sides of the box, more or less tightly, according to 

the condition of the limb 

and the degree of pressure 

requisite to retain the 

fragments of the bones in 

apposition ; the sides are 

thus secured by strips of 

muslin. If the pillow alone 

is insufficient to exert the 




Fig. 83. 



requisite pressure, com- 
presses should be used in 

addition, and these should be so placed as that the pressure 
may bear upon those particular points where they are most 
needed. Thus the proper shape of 
the limb may be easily preserved, 
being made more or less curved by 
the action of the pillow and com- 
presses. In this manner, some of 
the most marked deformities may 
be obviated. Thus, for example, in 
treating the fracture of which the 
annexed drawing from Fergusson's 
Practical Surgery (Am. ed., p. 304) 
illustrates the appearance, the leg 
should be placed in the fracture- 
box, as above directed, and a com- 
press be applied upon the tibial side 
of the limb, just above the promi- 
nence of bone, while another is laid 
on the fibular side, a little below the seat of fracture ; the 
compression exercised upon these points, when the sides of 
the box are closed, will suffice to restore the leg to its proper 
shape, and to retain the fragments in complete apposition. 
(Fig. 83.) 

The shape of the sound leg should be compared daily with 
that of the broken one, and any deviation from the proper 
line in the latter should be rectified in the manner pointed 
out. The foot should be kept upright against the foot-board, 
the heel supported by the pillow, and an additional pad, if 
necessary. If there be any signs of excoriation or sloughing 
on the heel, or malleoli, pressure should be immediately 




200 FRACTURES OF THE 

removed from these points, and brought to bear upon others, 
and the surface protected by simple cerate, or stimulated by 
frictions with spirits of camphor, soap liniment, &c, &c. Care 
is requisite lest the foot fall below its proper line, as com- 
pared with that of the sound leg ; to obviate this liability to 
displacement of the lower fragment, a pad of cotton should 
be placed under the heel. 

The advantages of the fracture-box are evident : it is per- 
fectly secure ; very simple in its construction ; fully capable 
of retaining in place the fragments of the bones, in the vast 
majority of fractures of the leg, and it leaves the limb always 
open to inspection, and for the application of local remedies. 
In very many cases of this fracture, it is necessary or advisa- 
ble to employ sedative lotions ; one of the best of these is the 
solution of the acetate of lead ; an objection to this, however, 
is that in many persons it irritates the skin too much, and in 
all it is apt to leave a deposition of the salt upon the surface, 
which is sometimes the source of irritation. When any liquid 
application is made, or any other dressing which may soil the 
pillow, a piece of soft oil-cloth should be spread upon the 
latter, before the leg is placed in the box. 

The fracture-box may be rendered more perfect by placing 
brackets in each side, through which pieces of iron-wire shall 
be passed, arching over the box to protect the limb from the 
pressure of the bed-clothes. 

Very often, indeed, in fractures of the leg, the skin will 
be found, in the course of a day or two after the accident, 
covered with small vesicles, particularly near the seat of the 
injury. This appearance, in persons of ordinarily good con- 
stitutions, is a matter of no importance, being indicative merely 
of a certain degree of irritation of the skin, which soon sub- 
sides under the application of cold water, and often it disap- 
pears if no local means are used ; but the same appearance in 
persons of bad constitution, especially in habitual drunkards, 
is frequently the precursor of erysipelas or mortification, and 
should be carefully watched. 

The most troublesome simple fracture of the leg is that in 
w T hich the tibia has been broken obliquely, the line of frac- 
ture extending downwards and forwards. Here the powerful 
muscles of the posterior surface of the leg draw the inferior 
fragment upwards, leaving the sharp extremity of the upper 



» BONES OF THE LEG. 201 

part of the bone projecting against the skin, and threatening 
to produce ulceration of the integuments at this point. Where 
this action of the muscles is but slight, the fracture-box may 
be employed, care being had that the inferior fragment, at 
the seat of the injury, is well supported by a compress placed 
beneath it. In other instances it will be necessary to adopt 
some plan of treatment which shall oppose the muscular con- 
traction by direct extension and counter-extension, or which 
shall produce the same effect by simply relaxing the muscles 
in question. If the first mode be resorted to, the splints 
advised by Dr. Hutchinson, of this city, may be employed. 
They are two in number, extending from the knee to some 
inches beyond the foot; the upper end of each splint has 
perforations made in it, for the attachment of the counter- 
extending bands, and at the lower extremity of each is a 
mortise, through which a bar is passed. The leg is laid upon 
a pillow, upon which a bandage of Scultetus is arranged ; 
tapes are secured upon each side of the leg, just below the 
knee, by means of a roller, and a gaiter, or a cravat, is fast- 
ened to the foot and ankle ; then the fracture having been re- 
duced, the leg is supported by an assistant, and the bandage 
of Scultetus folded upon it ; the splints are now placed by the 
sides of the leg, pads intervening, the counter-extending bands 
are fastened to the upper ends of the splints, and the extend- 
ing to the transverse bar passed through the mortises at the 
lower extremities, and the whole apparatus thus secured by 
strips of muslin tied around it. The long thigh splints of 
Desault may also be used for the same fracture, instead of the 
shorter splints of Hutchinson. 

Mr. Fergusson describes an apparatus contrived by himself 
and Mr. Weiss, which is intended to obviate the above men- 
tioned deformities resulting from muscular contraction. It 
consists of a straight bar of iron, extending from the knee 
beyond the sole of the foot, to which a foot-piece is attached 
in such a way as to be movable upwards towards the knee, 
and also laterally, so as to enable the surgeon to counteract 
any tendency to inversion or eversion of the foot : screws are 
so adjusted as to secure the different parts of the apparatus 
in any desired position. The lower extremity of the splint 
rests upon an upright arm, which reposes steadily upon the 



202 FRACTURES OF THE 

bed (fig. 84). For a more detailed exposition of this appara- 
tus, the reader is referred to Mr. Fergusson's book, p. 303. 

Fig. 84. 




Whichever of the apparatuses described shall be employed, 
the surgeon may, if he so choose, suspend the part, — a prac- 
tice supposed by many to be attended with advantages. At 
any rate, it serves very well to vary the position, and may 
thus add to the comfort of the patient. To accomplish the 
suspension, two or more strong iron bars may be made to 
arch over the limb, and the apparatus may be suspended 
from them. Or the more elegant arrangement of Mr. Salter, 
recommended and described by Mr. Fergusson, (p. 305,) may 
be used. It is " in most respects like a common metal cradle, 
but at the top will be seen a strong and smooth bar of iron, 
on which a couple of pulleys play ; these glide readily along 
the bar, and there is a hook attached to them below, to which, 
by means of a chain, a case for holding the leg is attached. 
When the leg is placed in this case, it will, in slight move- 
ments of the body, swing from the hook by means of the 
chain ; and in larger movements — as in using the bed-pan, or 
taking a new position in bed — -the pulleys will roll to and fro, 
so that there is no probability of the fragments gliding upon 
each other, or the seat of fracture being in any way disturbed. 
The case below is so constructed that various parts of it can 
be unhooked, so as to permit of dressings being applied in 
instances of compound fracture." (Fig. 85.) 

If the treatment by position is decided upon, the ordinary 
double inclined plane may be used, as advised in fractures 
of the thigh, a foot-board being attached to the lower plane, 
so that the foot may be well supported in the proper position. 



BONES OP THE LEG. 



203 



Or the fracture-box just described may be placed upona 
double inclined plane, and the leg properly arranged in it. 



Fig. 85. 




The last will probably be found to be the best plan, as the 
leg can thus be more securely disposed of, than when the 
plane alone is used ; in the latter case, lateral splints should 
be employed to steady the leg, and to make the necessary 
compression upon the sides. By thus flexing the knee, the 
muscles which draw up the lower fragment of the tibia are 
rendered almost inoperative, and the apposition of the two 
portions of bone is secured very readily ; a bandage of Scul- 
tetus may be advantageously employed for a few days, around 
the seat of fracture, but it should be removed daily, and the 
condition of the leg be inspected. 

Mr. Liston has devised a double inclined plane for the 
treatment of fractures of the leg, which he thinks superior to 
any other ; it is also well recommended by Fergusson and 
many other English surgeons. " It consists of a thigh and 
leg-piece of sheet-iron, and a foot-board of wood ; the former 
are joined to each other by a couple of hooks and a screw, 
which is so placed that the two plates can be set to any angle 
at which it may be desirable to bend the knee, and the foot- 
board is so affixed that it may be slid upwards or downwards, 



204 FRACTURES OF THE 

to suit the length of the limb, and fastened by a side screw 
in any position that may be advisable. At the lower end of 
the machine there is a cross-plate of iron, which is so attached 
that, in the event of the foot being raised or depressed, it 
will always rest flatwise on the mattrass, or on a board 
placed at the foot of the bed for the purpose of supporting 
it." (Fig. 86.) The limb is to be laid upon the splint, 
which has been well padded ; cotton or tow should be used to 
adapt the surfaces to each other, and to aid in making press- 
ure upon particular points, and a roller is then to be passed 
around the limb and the splint. The angle of the apparatus 
may be varied as may be judged proper. 

Fia. 86. 




2. If the tibia alone is broken, the displacement cannot be 
very great ; the accident may be treated by any of the methods 
above spoken of, or a splint of pasteboard, previously moulded 
to the leg, may be applied upon the inner or inferior surface, 
and confined by a roller, or by the starched bandage, and the 
limb kept at rest upon a pillow. But even in simple fracture 
of the tibia, it is safer to make use of the fracture-box, at least 
during the first week or ten days : the same precautions and 
attentions should be used during the treatment, as in the cases 
above considered, though they are less necessary. 

3. In fracture of the fibula only, when the injury has oc- 
curred above the lower three inches of the bone, nothing more 
than a simple lateral or angular displacement ensues, and the 
treatment demanded is the same as has been just advised for 
simple fracture of the tibia. But when the fracture has oc- 
curred at the lower two or three inches of the bone, consti- 
tuting what is called "Pott's fracture,'' a great lateral dis- 
placement is produced, rendered more remarkable by rupture 
of the internal lateral ligament of the ankle, which in the ma- 



BONES OF THE LEG, 



205 



Fig. 87. 




jority of cases is caused simultaneously with the fracture of 
the fibula. The annexed drawing, taken from 
Mr. Lonsdale's book, p. 522, exhibits the point 
at which the bone is usually broken, the rup- 
ture of the internal ligament, and the peculiar 
deformity ; (fig. 87,) and it shows the applica- 
bility of the mode of treatment recommended 
by Dupuytren. This method consists in the 
application to the tibial side of the leg of a 
splint and cushion of peculiar conformation. 
The cushion, made of cloth and filled two- 
thirds with chaff, should be two feet and a half 
long, four or five inches wide, and three or four 
inches thick. The splint, from eighteen to 
twenty inches long, two and a half inches wide, 
and three or four lines thick, should be made 
of firm and slightly flexible wood. Lastly, the 
two bandages used should be each four or five 
yards in length, and two and a half inches wide. 
The cushion, folded upon itself in the form of a 
wedge, is applied to the inner side of the fractured limb, upon 
the tibia, its base directed downwards, being laid upon the in- 
ternal malleolus, and not passing below it, its apex reposing 
upon the internal condyle of the femur. The splint laid upon 
this cushion should extend beyond it, from four to six inches, 
and beyond the inner edge of the foot three or four inches." 
One of the rollers is used to confine the upper part of the 
splint and cushion upon the leg, while the other draws the foot 
towards the inferior end of the splint, " being directed succes- 
sively from the latter over the upper surface of the foot, upon 
its outer side, under the sole of the foot, upon the splint ; then 
from this upon the instep and under the heel, to return again 
to the splint, and to be continued in the same manner until all 
the bandage is used. The foot is brought into such a state of 
adduction, that its external margin becomes inferior, the sole 
of the foot being directed inwards, and its internal edge up- 
wards." (Dupuytren, Lemons Orales, torn. i. p. 226.) The 
annexed figure illustrates the application of this splint. 
(Fig. 88.) 

Most cases of this fracture may be treated with complete 
success by the fracture-box. A reference to fig. 87 will show 
18 




206 FRACTURES OF THE 

the points upon which compresses should be placed, to rectify 
g8 the deformity ; viz. -one upon the external mal- 

leolus, and the other upon the side of the tibia, 
just above the extremity of the bone ; then, 
•when the sides of the box are brought up 
against the foot-board, the foot will be forced 
into its proper position, and thus retained. The 
advantages of Dupuytren's splint are, that the 
patient need not be confined to bed for any 
length of time, but may walk with his broken 
leg supported in a sling depending from the 
neck, or he may be allowed to travel, if his cir- 
cumstances require it, provided care be taken 
to support the member. 

The apparatus, whichever it be that is used 
in the treatment of fractures of the leg, may be 
suspended from the ceiling, or from the top of 
the bed, according to the plan recommended 
by Sauter and Mayor : this method has been 
already sufficiently explained, to enable the surgeon to adapt 
it to the fractures in question. It is difficult, however, to see the 
particular advantages which would result from such a modi- 
fication of the stationary apparatus. 

When fractures of the leg occur in persons who are at the 
same time affected with mania-a-potu, perhaps the most secure 
bandage will be the starch bandage with splints of pasteboard. 
4. Compound fractures of the leg must be treated after the 
general principles recommended in similar injuries of the arm 
and thigh. The bran-dressing, first resorted to by Dr. J. K. 
Barton, of this city, and to which allusion has been before 
made in these pages, is particularly well adapted to the treat- 
ment of compound fractures of the leg. In such cases, the 
bran is used as a substitute for the pillow employed in simple 
fractures. The fracture-box has a sufficient quantity of the 
bran laid upon the bottom of it, to afford a soft resting-place 
for the leg ; the leg is placed upon it, the form of the limb ad- 
justed as well as possible, the foot is properly attached to the 
foot-board ; then the sides of the box are closed, and the box 
itself filled with bran. The requisite degree of lateral pres- 
sure can generally be gained by packing the bran pretty firmly 
opposite particular parts of the leg : and in addition, a few 



BONES OF THE LEG. 207 

strips of adhesive plaster may be drawn around the limb at 
the point of fracture, without closing the wound entirely, or 
materially interfering with the ready exit of the pus. Thus 
the leg is imbedded in the midst of a substance which absorbs 
at once the discharged matters ; which diminishes the unplea- 
sant foetor, by secluding the pus from the action of the air ; 
which is itself clean, light, and cool, and which is easily re- 
newed. It will be found, moreover, to be the most effectual 
mode of preventing the deposition of the ova of flies and other 
insects which, in our warm summers, become developed in the 
wound and are the source of great inconvenience and annoy- 
ance. 

The disposition to the formation of abscesses at points 
remote from the wound is often met with in compound frac- 
tures of the leg. When formed, they should be opened as 
soon as possible, and the matter confined between the point 
of incision and the original wound by a few strips of the 
bandage of Scultetus laid above the seat of abscess, or below 
it, as the case may be. 

Very generally in these injuries, the wound is on the ante- 
rior face of the leg ; but it sometimes happens that the in- 
teguments are ruptured on the posterior face, or on one side ; 
in the latter cases the fracture-box may still be employed, 
care being had that too great pressure is not exercised upon 
the wound itself. But when the solution of continuity exists 
on the posterior part of the leg, some apparatus must be re- 
sorted to which will allow the limb to repose upon its side. 
For this purpose, a wooden splint may be used, grooved to 
receive the leg, and terminating below in a foot-piece. The 
patient should repose upon his side, the thigh and leg flexed 
and resting upon pillows. The broken leg should be placed 
in the splint, (on the side opposite to the wound, so as to 
leave the latter exposed,) and confined to the splint at the 
knee and at the foot, by means of rollers. Little force will 
be required, generally, to retain the fragments in apposition, 
the flexed position in which the whole limb is placed itself 
relaxing the muscles : but compression may be resorted to, if 
necessary, by strips of adhesive plaster, or of the bandage 
of Scultetus, laid above and below the wound, while this is 
covered with a poultice, or some other suitable dressing ; the 
pillows should be protected by a piece of oil-cloth, upon 



208 FRACTURES OF THE 

which bran, cotton, or any absorbing material, should be 
placed, to catch the discharges from the wound. 



SECTION IV. 
FOR FRACTURES OF THE BONES OF THE FOOT. 

Very little displacement accompanies simple fractures of 
the bones of the foot, as a general rule, and therefore the 
treatment is very simple. The foot should be kept at rest, 
with a splint of wood, or of pasteboard, bound to its sole, 
and a broad compress applied on the superior surface. Or 
an equally good plan consists in placing the leg in a fracture- 
box, with the sole of the foot confined to the foot-board, by 
a broad band, which leaves the dorsum of the foot sufficiently 
exposed to the action of local antiphlogistic applications. 

When the posterior extremity of the os calcis is broken, 
there need not be much displacement, if, as is generally the 
case, the strong plantar ligaments connected with this part 
of the bone remain unruptured. Under other circumstances, 
however, the fragment is more or less drawn from its natural 
position, by the contraction of the gastrocnemius and soleus 
muscles, and the treatment employed must be adapted to 
counteract their influence. For this purpose the apparatus 
recommended by Mr. Lonsdale is very simple and effectual. 
It consists of a foot-piece of wood, to the extremity of which 
the end of a slipper is attached, for the reception of the toes. 
The foot-board should be rather shorter than the sole, so as 
to extend from the toes not quite Co the heel ; to its under 
surface a ring is attached. A pad, or compress, is placed 
upon the extremity of the os calcis, (the fragment having 
been restored to its proper position), and confined thus by a 
few turns of a roller ; then a strap of leather, or a band of 
webbing, is passed through the ring of the foot-board, 
upwards over the heel and the pad, over the calf of the leg 
to the lower third of the thigh, where it is reflected upon 
itself, — the knee being flexed, and the foot extended, — and 
confined to the surface by turns of a roller, (fig. 89.) 

This same apparatus will answer for the treatment of rup- 
ture of the tendo Achillis, with the addition of a roller 



BONES OF THE FOOT. 



209 



Fig. 



Fig. 90. 





applied carefully from the toes to the knee. The same effect 
may be gained by a method even more simple than this, as 
follows : Encircle the lower part of the thigh with a strap, or 
a roller tightly applied, and connect this, by means of a 
strip of muslin, to the heel of a slipper placed upon the foot, 
— the leg being flexed upon the thigh ; envelope the foot and 
leg in a roller. The annexed drawing, from Druitt, exhibits 
this plan of treatment, (fig. 90.) 

In compound fractures of the bones, the foot should be 
kept in the same position as in case of simple fracture, with 
a poultice, or other proper dressing applied over the part, 6 



18* 



PAET IV. 

ON THE MECHANICAL MEANS EMPLOYED IN THE TREAT- 
MENT OF DISLOCATIONS. 

A dislocation, or luxation, is defined by Sir Astley 
Cooper to be, " a displacement of the articulating portion of 
a bone from the surface on which it was naturally received. " 
This faulty position is maintained, and the reduction of the 
dislocation opposed, by a combination of causes ; sometimes, 
and partially, by the conformation of the bony surface on 
which the displaced member rests, as the prominent margin 
of the acetabulum, in dislocations of the hip ;— occasionally, 
to a certain extent, by the situation and condition of the liga- 
ments about the joint ; — but chiefly and in every case, by the 
powerful clonic and tonic action of the muscles. These ob- 
stacles cannot be overcome without resort, on the part of the 
surgeon, to physical force. 

It does not fall within the province of this volume to dis- 
cuss the pathology of this class of accidents ; its limits and 
its legitimate intention permit only a description of the me- 
chanical means employed in their treatment. The subject 
naturally divides itself into two branches : 1st, the means of 
reducing the dislocation, or of restoring the displaced bone to 
its natural situation ; 2d, the mode of retaining the bone in 
place, until the necessary reparation of the injury done to 
the tissues shall have become perfected. 

Luxations are replaced by means of muscular force acting 
directly upon the two bones involved, or indirectly through 
the intervention of some mechanical apparatus, the object of 
which is to increase the power of the muscles, and to render 
it more uniform and more equable in its operation. The force 
thus excited must act in two opposite directions: one, — the 
extending, — upon the movable part, that which has been dis- 
placed ; while the counter-extension is exercised on the oppo- 
site part, serving merely to fix and steady it. The points 

(210) 



DISLOCATIONS. 211 

upon which these forces operate vary in different dislocations : 
generally, the muscles which directly surround the joint, and 
which, if they are excited to contraction by any cause, 
may interfere with the execution of the object in view, should 
not be compressed by the extending and counter-extending 
powers, unless from motives of convenience and expediency. 

To assist the action of the mechanical means, in all in- 
stances where the resistance of the muscles is great, or where 
much pain is likely to be experienced for any length of time, 
it is important to depress the irritability and power of the 
muscles, and the nervous sensibility, by anaesthetics, or some 
other agent. 

When the dislocation has been reduced, there is, generally, 
but little disposition to re-displacement : it is necessary merely 
to keep the muscles surrounding the joint, and the joint itself, 
in a state of repose, for a certain time. This object is secured 
by the application of retentive bandages and splints. 

The special dislocations will be briefly considered, with 
particular reference to the mode in which the various me- 
chanical means alluded to are applied. 



CHAPTER I. 

DISLOCATIONS OF THE BONES OF THE HEAD AND TRUNK. 

SECTION I. 

DISLOCATION OF THE LOWER JAW. 



Reduction. — In this accident the articular surface of one, 

or of both, of the condyloid processes of the inferior maxilla 

rests upon the base of the zygomatic process, being thrown 

„ „ forwards out of the 

Fig. 9 It i -j 

glenoid cavity, as is 

represented in the an- 
nexed wood cut, (fig. 
91.) To remedy the 
deformity, the surgeon 
places his thumbs, well 
wrapped around with 
muslin, to protect them 
from injury, between 
the posterior molar 
teeth on each side of 
the jaw, grasping the 
base of the bone on 
each side with his fin- 
gers ; then, the patient's head being well supported against 
the back of a chair, or by the hands of an assistant, the sur- 
geon presses his thumbs strongly downwards upon the molar 
teeth, while with his fingers he forces the chin upwards ; thus 
the condyloid processes are removed from their false position, 
and by the contraction of the muscles connected with the 
posterior part of the bone, are draw r n into the glenoid 
cavities. 

The succeeding treatment consists in the application of a 
simple retentive bandage, as that of Barton, or of Gibson, 

(212) 




DISLOCATIONS OF THE CLAVICLE. 213 

(see Fractures of Lower Jaw,) and in nourishing the patient 
for the following two or three weeks with liquid food. 



SECTION II. 
DISLOCATIONS OF THE BONES OF THE TRUNK. 

If the vertebrae, the ribs, or the bones of the pelvis chance 
to be separated from their articular connexions, the accident 
is generally accompanied by other serious, if not fatal, in- 
juries to the organs contained in the thoracic, abdominal and 
pelvic cavities. The surgeon can do little or nothing towards 
replacing the dislocated bones. Perfect rest should be en- 
joined, with the use of such local and general antiphlogistic 
remedies as may be requisite. The simple body-bandage for 
the chest, or pelvis, will effect all that can be expected of 
any mechanical contrivance ; or the bandages shown in figures 
29, 31 and 76 may be employed, according to the region 
injured. 

SECTION III. 
DISLOCATIONS OF THE CLAVICLE. 

Either articular extremity of the clavicle may be luxated : 
the modes of effecting reduction are very similar in all varie- 
ties of the accident. The patient being seated, the surgeon 
takes a position behind him, grasping each shoulder, and 
having one knee placed against the spine between the shoul- 
ders, so as to steady the patient, w T hile he draws the shoulders 
backwards, and thus operates upon the clavicle. The natu- 
ral distance between the , shoulders having been regained, 
pressure must be made upon the extremity of the reduced 
bone with the hand, until a suitable bandage can be applied. 

After-treatment. — The retentive means employed to 
maintain the reduction should accomplish two indications ; 
viz., to prevent the shoulder from falling downwards, for- 
wards, and inwards, and to exert a certain degree of pressure 



214 



DISLOCATIONS OF THE CLAVICLE. 



upon the dislocated extremity of the clavicle. If the humeral 
end of the bone has been luxated, both of these indications 

will be fulfilled by the appli- 
Eig.92. cation of the figure-8 ban- 

dage of both shoulders, a pad 
being placed in the axilla of 
the affected side and a- com- 
press upon the end of the bone 
(fig. 92), while the fore-arm 
is supported in a sling upon 
the front of the chest. If 
the accident has occurred to 
the sternal extremity of the 
clavicle, the same bandage 
should be employed, with the 
addition of a compress upon 
the injured articulation, to 
be retained in this situation 
by means of a few turns of a 
roller made to encircle ob- 
liquely the upper part of the chest, passing across the root 
of the neck of the injured side, over the sternal extremity of 
the clavicle, under the axilla of the sound side, and so around 
the back to the starting-point. Dr. W. Poyntell Johnston, 
some years ago lecturer on Surgery in this city, was in the 
habit of recommending the use of the common hernia-truss in 
the treatment of this accident, the pad being made to press 
upon that extremity of the clavicle which had been dislocated ; 
the truss can be easily secured in position by a few turns of 
a roller, or by a handkerchief. 




CHAPTER II. 

DISLOCATIONS OF THE BONES OF THE UPPER 
EXTREMITY. 

SECTION I. 

DISLOCATIONS OF THE HUMERUS. 

The head of the humerus is liable to three principal varie- 
ties of displacement, viz., 1st, in the direction downwards into 
the axilla; 2d, forwards, under the pect oralis major muscle; 
3d, on the dorsum of the scapula. 

In all of these, the principle of reduction is the same, vary- 
ing only in the line in which the reducing force is made to 
operate. There are, however, several methods by which the 
restoration may be accomplished. 

1. By the heel in the axilla. The patient should assume 
the recumbent position on a bed, or on the floor; the surgeon 
sits by his side, and places one heel in the axilla, in contact 
with the head of the humerus, thus fixing the body; the 
extending force is applied either to the arm above the elbow, 
or to the wrist. By the former plan, the surgeon flexes the 
patient's fore-arm so as to relax the biceps muscle, and secures 
a double roller-towel upon the arm above the elbow, by means 
of a wetted bandage ; he then passes the towel over his own 
neck, and under the axilla of the side next the patient. 
(Fig. 93.) It may be objected to this method, that the 
triceps and biceps muscles may be stimulated to contraction 
by the pressure exercised upon them, and thus oppose the 
reduction. By the other mode, the surgeon grasps the pa- 
tient's wrist either with the hand, or through the medium of 
a bandage, or of a double towel arranged in the manner above 
described. The last method is probably the best, as it does 
not directly affect the muscles which pass from the scapula to 
the lower part of the humerus and the fore-arm. By employ- 
ing the double towel, in either mode of operating, the surgeon 
may avail himself of the power of the muscles of the back, 

(215) 



216 



DISLOCATIONS OF THE HUMERUS. 



as well as of those of the arms. The extension should be 
made gradually and steadily in the direction assumed by the 



Fig. 93. 




humerus, and the head of the bone may be acted upon by the 
heel of the surgeon also, so as to be dislodged from its position 
in the axilla. 

2. By relaxing the supra-spinatus muscle and the deltoid, 
•which, according to Sir A. Cooper (op. cit. pp. 321, 2), are 



Fig. 94. 




the chief opponents of the reduction. The patient lies down, 
as in the first method; the surgeon sits behind him, and 



DISLOCATIONS OF THE HUMERUS. 



217 



extends the dislocated arm with one hand, while with the 
other he fixes the scapula. (Fig. 94.) If this simple manual 
force is not sufficient, the scapula may be secured by means 
of a double towel passed around it, crossing the axilla, and 
confined to the bedstead, or to the floor, on the opposite side 
of the patient ; while pulleys are employed to make the ne- 
cessary extension, as will be explained directly ; or, again, 
extension may be effected by means of the double towel 
passed around the surgeon's back and shoulder, as already 
described. 

3. By the pulleys. It is necessary, in the employment of 
the pulleys, to fix the scapula by some mechanical means. 
This may be best accomplished by a broad piece of canvass, 
or leather, in which a hole is made large enough to admit the 
shoulder ; this band should pass in front of and behind the 
chest, and be secured to a hook in the wall, or the floor, if the 
patient is in the recumbent position. The annexed drawings 
from Fergusson, illustrate the kind of pulleys which are used, 

Fig. 95. 




and the ring to which one of their hooks is attached during 
the extension. (Fig. 95.) The other hook should be fas- 
tened to a towel, which has been secured upon the arm above 
the elbow, by means of a wetted roller. The cord of the 
pulleys should be drawn, by an assistant, slowly and steadily, 
and be relaxed as soon as the surgeon, who has his hands 
upon the head of the bone and the shoulder, feels that the 
former has been drawn out from beneath the glenoid cavity. 
19 



218 DISLOCATIONS OF THE HUMERUS. 

It may be of service sometimes, that the surgeon should place 
his knee beneath the humerus near to its head, in order to 
gain a fulcrum upon which, by depressing the elbow, the 
head of the bone may be elevated towards the glenoid cavity. 
(Fig. 96.) 

Fig. 96. 




The use of the pulleys is necessary in cases where, from 
long-standing dislocations, or from the great muscular powers 
of the individual, a very considerable, and a very steady and 
long-sustained force is required to reduce the head of the 
bone. In such instances, resort should be had to general de- 
pressing means, as bleeding, the administration of nauseating 
doses of tartar emetic, &c. 

Any of the varieties of dislocation of the humerus may be re- 
duced by these means, but the direction in which the extending 
force should act, must be modified with each luxation. In 
the dislocation downwards, the arm should be drawn down- 
wards and a little outwards from the side, to correspond with 
the direction of the axis of the humerus. In the luxation 
forwards, the arm points outwards and backwards, and the 
reducing force should operate in the same direction. When 



DISLOCATIONS OF THE HUMERUS. 219 

the head of the bone is thrown upon the dorsum of the scapula, 
the extension must be made forwards and outwards. 

A complicated and expensive, though ingenious apparatus, 
known in this country and in Europe as " Jarviss Adjuster" 
was invented some years ago by Dr. Gr. 0. Jarvis, of Connec- 
ticut. It consists of several pieces of iron, shaped to corre- 
spond with the form of the different parts of the upper and 
lower extremities ; these are to be secured upon the dislocated 
member by means of straps and buckles. The extending 
power, which accomplishes the reduction, is applied by means 
of a rack-and-pinion-wheel. It is applicable both to disloca- 
tions and to fractures. Those who are desirous of seeing 
representations of the apparatus, and the manner in which it 
is to be employed, we would refer to a series of lectures upon 
the subject by its inventor, published in the London Lancet, 
for 1846, Vol. I. _ 

The apparatus is a very powerful one, unquestionably, and, 
we dare say, can be made to accomplish what its maker 
promises. But we believe, that with the ordinary pulleys, 
aided by anaesthetic influence, the surgeon can exert as much 
force as is necessary or safe, and can direct it perhaps better 
than by the " Adjuster." Moreover, (and this we think a 
very important consideration !) the surgeon knows how much 
force he employs, if he uses the pulleys; whereas, if he 
brings the apparatus in question to bear upon a dislocation or 
fracture, he cannot judge of this so accurately, and he is 
consequently much more likely to do mischief in his efforts 
to benefit his patient. These considerations, together with 
the costliness and complicated character of the machine, and 
the fact that we can succeed very well with the means which 
have been so long in use, render it hardly worth while to 
burthen ourselves with "Jarvis s Adjuster." 

After-treatment. — The fore-arm should be supported in 
a sling, in the semi-flexed position, on the chest, a pad should 
be secured in the axilla, and the arm bound, with a moderate 
degree of pressure, to the side. Local antiphlogistic applica- 
tions, as lead-water, cold poultices, or leeches, may be made 
as required. The apparatus should be continued for ten days 
or two weeks. 



220 DISLOCATIONS AT THE ELBOW-JOINT. 

SECTION II. 
DISLOCATIONS AT THE ELBOW-JOINT, 

Of these there are six varieties : 1st, in which both bones 
are thrown backwards, the olecranon process projecting very 
much posteriorly ; 2d, in which both bones are drawn back- 
wards and inwards ; 3d, when both are thrown backwards and 
outwards; 4th, the ulna alone is forced backwards, the 
orbicular ligament of the radius being ruptured, but this bone 
itself remaining on the anterior face of the external condyle ; 
5th, the radius forced forwards into the depression above the 
external condyle, the ulna remaining in situ ; 6th, the radius 
thrown backwards behind the external condyle of the humerus. 
In all the varieties the reduction is generally easily effected. 
In the first four species, the restoration may be accomplished 
by placing the knee at the bend of the elbow, and flexing the 
fore-arm upon it, the lower part of the upper arm and the 
fore-arm being grasped by the hands of the surgeon. The 
dislocations of the radius may be remedied by fixing the 
humerus and making extension from the hand, while the bone 
is thrown forwards ; if the luxation be backwards, the same 
extension and counter-extension should be made, while at the 
same time the fore-arm should be flexed, thus forcing the 
biceps to draw the radius to its proper place. 

Subsequent Treatment. — The fore-arm should be placed 
in the semi-flexed position, and an angular splint should be 
bandaged upon the front of the whole limb, compresses being 
placed upon the head of the bones opposite the direction of 
the luxation. This confinement must be maintained for two 
or three weeks, passive motion being carefully instituted after 
the first few days. 



DISLOCATIONS OF THE FORE-ARM. 221 

SECTION III. 

DISLOCATIONS OF THE LOWER EXTREMITY OF THE FORE-ARM. 

These accidents are usually caused by falls upon the hand. 
Both the radius and ulna may be thrown either backwards or 
forwards upon the wrist, causing considerable projection in 
these situations, or one of the bones only of the fore-arm may 
be separated from its connexions and displaced anteriorly, pos- 
teriorly, or laterally. The reduction is easily accomplished 
by simply extending and counter-extending from the hand and 
the fore-arm, and making moderate lateral pressure at the 
same time, if the displacement be at the side of the wrist. 

Subsequent treatment. — Place a straight splint on the 
front, and another on the back of the fore-arm and hand, with 
compresses on the anterior and posterior surfaces of the wrist, 
and secure the whole by a roller. The fore-arm should be 
supported in a sling. 



SECTION IV. 
DISLOCATIONS OF THE BONES OF THE HAND. 

Instances have been met with, in which some one or more 
of the carpal bones have been thrown from their natural posi- 
tions, so as to form projections upon the back of the hand, 
without a wound of the integuments. They may generally be 
replaced by pressure : the reduction should be maintained, by 
placing compresses upon the palmar and dorsal aspects of the 
wrist, and upon these straight splints, the whole to be enve- 
loped in the folds of a roller. The hand should be supported 
in a sling. 

The same treatment, conjoined with some degree of exten- 
sion in the reduction, is applicable to dislocations of the meta- 
carpal bones, should they occur without laceration of the in- 
teguments. 
19* 



222 



DISLOCATIONS OF THE HAND. 



Dislocations of the phalanges may ordinarily be reduced 
•without much difficulty, if the accident is attended to soon 
after its occurrence. Sometimes restoration may be accom- 
plished by simply bending the displaced phalanx over the head 
of the bone from which it has been dislocated, as represented 
in the annexed drawing. (Fig. 97.) Frequently, however, con- 

Fig. 97. 




siderable extension and counter-extension are requisite. To 
effect this, a piece of cord should be wound around the pha- 
lanx, the skin being protected by a covering of wetted buck- 
skin ; then, the hand being fixed, the surgeon should extend 
the finger, at first in the axis of the bone, and gradually flex 
it towards the palm, in order to relax the flexor muscles, if 
the dislocation be posteriorly; or, if the phalanx has been 
thrown upon the palmar face of the other bone, it should be 
forced a little backwards, during the extension. (Fig. 98.) 

Fig. 98. 




The most convenient mode of securing the extending cord 
or tape, is by making what is termed the " clove-hitch/ ' as 
shown in the accompanying drawing, (fig. 99,) from Fer- 
gusson. • 



DISLOCATIONS OF THE HAND. 



223 



Fig. 99. 



Dislocation of the phalanges of the thumb is most difficult of 
reduction. The following is the 
method recommended by Sir A. 
Cooper, p. 446 : " The extension 
is to be made by bending the 
thumb towards the palm of the 
hand, to relax the flexor muscles 
as much as possible, and the fol- 
lowing is the mode of applying 
the extending force : The hand 
is to be first steeped in warm 
water for a considerable time, to 
relax the parts as much as pos- 
sible ; then a piece of thin wetted 
leather is to be put around the 
phalanx, and as closely adapted to the thumb as possible : a 
piece of tape about two yards in length is next to be applied 
upon the surface of the leather, in the knot called the " clove- 
hitch," for this becomes tighter as the extension proceeds. 
An assistant places his middle and forefinger between the 
thumb and forefinger of the patient, and makes the counter- 
extension, whilst the surgeon, assisted by others, draws the 
phalanx from the metacarpal bone, directing it a little inward 
towards the palm of the hand." (Fig. 100.) 

Fig. 100. 





The quiescence of the joint after dislocation of the metacar- 
pal, or phalangeal bones, is to be maintained by splints and 
compresses placed upon the dorsal and palmar aspects of the 
hand. 



CHAPTER III. 

DISLOCATIONS OF THE BONES OF THE LOWER EXTREMITY. 

SECTION I. 

DISLOCATIONS OF THE HIP-JOINT. 

Of these there are four chief varieties, named from the 
false position which the head of the os femoris assumes ; they 
are as follows : — 1st, upwards, or on the dorsum ilii ; 2d, 
downwards, or into the foramen ovale; 3d, backwards and 
upwards, or into the ischiatic notch ; 4th, forwards and up- 
wards, or on the body of the pubis. 

These require, on the part of the surgeon, the employment 
of a greater degree of force in reduction than dislocations of 
any other bone, owing to the much greater power of the 
muscles concerned. In young children they may generally 
be restored by simple manual extension and counter-extension, 
as the luxations of the humerus ; but in adults, the pulleys 
should always be employed, and it is almost always advisable 
to have recourse also to depressing agencies, as bleedijig to 
the amount of from twelve to twenty ounces, or the hot-bath 
at 100°, or the administration of tartar emetic in doses of 
half a grain every ten minutes, until nausea is produced, or, 
still better, probably, by bringing the patient under the 
anaesthetic influence of ether or chloroform. 

As in other dislocations, the reducing forces should act 
gradually and steadily, and in the line of the axis of the 
dislocated bone, and during their operation, the patient's 
mind should be interested, if possible, in some subject other 
than his accident. 

The treatment of the individual dislocations is as follows : — 

1st. The dislocation upwards on the dorsum ilii. The 
patient is placed upon a table covered with a mattrass, or 

(224) 



DISLOCATIONS OF THE HIP-JOINT. 



225 



folded blankets. The pelvis is fixed by means of a sheet 
folded longitudinally, passed under the perineum and over the 
crista of the ilium, and secured to a staple so situated that 
the sheet may be in a line with the axis of the thigh. The 
extension is effected through the intervention of a wetted 
roller secured upon the lower part of the thigh, and having 
buckled around it a leathern band with a short strap on each 
side terminating in a ring ; the two rings are to be attached 
to the hook of the pulleys, and the latter secured to a staple 
in such a position that the extending and counter-extending 
forces may act parallelly to each other, from opposite points, 
and to the axis of the bone. Instead of the leathern band, 
a double towel may be confined to the thigh by the clove-hitch. 
The knee of the dislocated limb should be bent nearly at 
right angle and pointed across the thigh a little above the 
knee of the other leg. After the muscles have been fatigued 
by the continued action of the pulleys, the surgeon should 
grasp the knee, and rotate the hip slightly and gently, or he 
may pass a towel around the upper part of the thigh, and 
raise thereby the head of the bone, when it will usually slip 
into the acetabulum, (fig. 101). 

Fig. 101. 




The subsequent treatment consists in keeping the patient 
in bed for two weeks or more, his knees tied to each other by 
a strip of muslin, and a broad belt passed around his pelvis 
pressing upon the trochanters. 

2d. The dislocation downwards, or into the foramen ovale. 
To reduce this luxation, the following course should be pur- 
sued : The patient should be in the recumbent position, as in 



226 



DISLOCATIONS OF THE HIP-JOINT. 



Fig. 102. 



the first case; a girth made of leather, or of a sheet, or 

towel, should be passed 
around the upper part of 
the thigh and attached to 
one of the hooks of the 
pulleys, the other being 
secured to a staple fixed 
in the wall opposite the 
dislocated hip ; another 
girth should be made to 
encircle the pelvis, so as 
to steady the body, pass- 
ing the noose formed by 
the first girth, and at- 
tached to a staple placed 
opposite to the first, on 
the sound side of the 
patient. The cord of 
the pulleys should now 
be drawn until the head 
of the femur begins to 
leave its position in the 
foramen ovale, when the 
surgeon should pass his 
hand behind the ankle 
of the sound limb, and 
grasp the other ankle, 
which he draws steadily 
towards him ; the effect 
of this is, to throw the head of the bone outwards, the limb 
being a lever with its fulcrum on the extending girth ; as soon 
as the head of the femur is sufficiently disengaged from its 
false position, the extending force should be suspended, when 
the limb will be restored, (fig. 102.) 

The after-treatment is as in the first case. 
3d. To reduce the dislocation backwards, or into the 
ischiatic notch : — Secure the extending and counter-extending 
bands as in the first species of luxation ; then, the patient 
reposing upon his sound side, the knee of the dislocated limb 
should be pointed across the middle of the opposite thigh, 
and the extension practised until the muscles are enfeebled ; 




DISLOCATIONS OF THE HIP-JOINT. 



227 



a round towel should now be passed under the upper part of 
the thigh, and over the shoulders of an assistant, who should 
be directed to press upon the pelvis with his hands, and at 
the same time to raise his shoulders : thus the head of the 
femur will be extricated from the ischiatic notch, and drawn 
downwards into the acetabulum. (Fig. 103.) 

Fig. 103. 




The subsequent treatment does not differ from that advised 
*or the other cases. 

4th. To restore the luxation forwards and upwards, or on 
the pubis : — The apparatus employed is the same as has been 
already described, and its mode of application is as in the 
ast-named variety of the accident. The patient should be 
Dlaced upon his sound side, the knees widely separated from 
each other, and the extension made in a line behind the axis 
of the body. When the muscles have been sufficiently 
fatigued, a round towel should be passed under the upper 
part of the thigh, and around the shoulders of an assistant, 
who elevates the head of the femur by raising his shoulders, 
pressing at the same time upon the pelvis. (Fig. 104.) 

After-treatment. — The same as in the other varieties. 

A very good and simple substitute for the pulleys has been 
recently recommended by Dr. Gilbert, Professor of Surgery 
in the Pennsylvania Medical College. Its mode of applica- 
tion is thus described in the American Journal of Medical 
Sciences, vol. ix., N. S. : — "Place the patient and adjust the 
extending and counter-extending bands as for the pulleys ; 
then procure an ordinary bed-cord, or a wash-line; tie the 



228 DISLOCATIONS OF THE HIP-JOINT. 

Fig. 104. 




ends together, and again double it upon itself, pass it through 
the extending tapes or towel, doubling the whole once more, 
and fasten the distal end, consisting of four loops of rope, to 
a window-sill, door-sill, or staple, so that the cords are drawn 
moderately tight; finally, pass a stick through the centre of 
the doubled rope, then by revolving the stick as an axis, or 
double lever, the power is produced precisely as it should be 
in such cases, viz. : slowly, steadily, and continuously." 
(Fig. 105.) 

Fig. 105. 




Several instances of anomalous dislocations of the head 
of the femur are recorded by Cooper and others. (Sir A. 
Cooper, op. cit., pp. 83-97.) The means employed in the 



DISLOCATIONS OF THE PATELLA. 229 

treatment of these are the same as in those varieties which 
have been already described. Proper reflection upon such 
cases will enable the surgeon to determine the probable posi- 
tion of the head of the bone, and the line in which the ex- 
tension and counter-extension should be made, together with 
such other expedients as will assist in the dislodgement of 
the head of the bone from its unnatural position. 



SECTION II. 
DISLOCATIONS OF THE PATELLA. 

The patella is liable to displacement in two directions, 
without rupture of its tendon or ligament, viz. : 

1st. Dislocation outwards, the bone resting upon the exter- 
nal condyle of the os femoris, causing great projection at this 
point, and an inability to flex the knee. 

2d. Dislocation inwards, producing the same difficulty in 
bending the knee, with a marked prominence at the inner 
condyle of the femur. 

The restoration is generally easily accomplished, by re- 
laxing the extensor muscles of the leg : for this purpose the 
heel should be elevated upon the shoulder of an assistant, 
while the surgeon presses down the edge of the patella 
which is most removed from the centre of the knee-joint, 
thus tilting up the other edge of the bone, when the mus- 
cles, aided by a lateral pressure, will draw the patella to its 
place. 

The subsequent treatment consists in confining a straight 
splint to the posterior surface of the limb, and in making 
moderate pressure upon the knee by means of a roller, or a 
laced bandage; local antiphlogistic applications are gene- 
rally required, in addition. The patient should be confined 
to bed for about two weeks. 

20 



230 DISLOCATIONS OF HEAD OF FIBULA. 

SECTION III. 
DISLOCATIONS OF THE TIBIA AT THE KNEE. 

. Of these there are four varieties, viz. : 

1st. Displacement forwards, — the tibia being thrown upon 
the anterior part of the thigh, of which the condyles are de- 
pressed backwards, and somewhat to the side. (Cooper.) 

2d. Backwards, — the tibia drawn upwards behind the con- 
dyles of the femur, which project very much on the front of 
the leg. 

3d. Inwards, — the internal condyle of the thigh-bone rest- 
ing upon the external semilunar cartilage. 

4th. Outwards, — the inner semilunar cartilage being in con- 
tact with the external condyle of the femur : the great lateral 
projection of the head of the tibia in these cases renders the 
diagnosis of the injury very easy. 

These dislocations are readily reduced by making exten- 
sion and counter-extension from the ankle and thigh, con- 
joined with moderate pressure upon the head of the tibia. 
After the restoration is accomplished, the limb should be 
secured to a straight splint, and such local antiphlogistic 
means should be employed as the circumstances of each case 
may call for. The patient should be kept in bed for ten 
days or two weeks, or longer, if there be continuance of pain 
or of inflammation. 

SECTION IV. 
DISLOCATIONS OF THE HEAD OF THE FIBULA. 

The head of the fibula is sometimes detached from its 
connexions with the tibia, and drawn backwards by the 
action of the biceps. It is easily restored to its place, by 
flexing the leg so as to relax this muscle, and pressing the 
bone forwards. 

In order to retain it "in situ," the leg should be kept bent 
over a pillow, or an inclined plane, with a compress bound 



DISLOCATIONS OF THE ANKLE. 281 

against the posterior part of the head of the bone by means 
of a roller. 



SECTION V. 
DISLOCATIONS OF THE ANKLE. 

The astragalus may be separated from the bones of the 
leg in four directions, viz. : forwards, backwards, outwards, 
and inwards. The recognition of the accident is easy, and 
the reduction not difficult. The limb should be flexed, so 
as to relax the powerful muscles on the back of the leg ; 
then, while extension and counter-extension are made from 
the foot and the lower part of the thigh, the surgeon should 
press firmly upon the dislocated bone, and thus force it to its 
place. 

After reduction, the leg and foot should be confined in 
carved splints, or splints made of binders' board, soaked in 
hot water and moulded to the shape of the limb, with a foot- 
piece at right angles ; or a fracture-box will be found to 
answer equally well. This confinement to bed and in splints 
should continue for five or six weeks, and when the patient 
is first allowed to walk, the ankle should be carefully sup- 
ported by a roller bandage, or a firm laced gaiter. The time 
requisite to perfect the cure of these accidents is, according to 
Sir A. Cooper, ten or twelve w r eeks. 

If the fibula alone is separated from the tibia, simple late- 
ral pressure will restore it to its place, after which a roller 
and compress should be employed for some weeks to retain the 
bones in apposition ; rest is necessary, as in the last-described 
injury. 

The remarks made on the treatment of dislocations of the 
bones of the hand and wrist are applicable to the same kinds 
of injury of the foot ; the treatment to be pursued in the re- 
duction, and subsequently, is similar, excepting that a greater 
degree of force is required to reduce the luxation, and a longer 
confinement afterwards, when the foot is involved than when 
the hand is injured. 



CHAPTER IV. 

COMPOUND DISLOCATIONS. 

These accidents require the same sort of treatment as com- 
pound fractures. Much experience, and careful examination 
of all the circumstances connected with each case, are neces- 
sary to enable the surgeon to determine when to attempt to 
save a limb so injured, and when to amputate. This volume 
does not pretend to lay down rules for such cases. The 
reader will do well to consult the works of the Coopers, Vidal 
(de Cassis), Boyer, Chelius, and others, with reference to this 
important subject. 

If an attempt to save the limb be decided on, the wound 
should be carefully cleansed, all foreign bodies, spicula, or 
small and detached fragments of bone, removed, hemorrhage 
arrested, and the dislocated bone restored, if possible. Then 
the edges of the wound should be apposed to each other, and 
covered, as in the case of compound fractures of the patella, 
&c, with a piece of lint dipped in blood, or in some aggluti- 
native fluid, and every effort should be made to convert the 
injury into a simple dislocation. The tendency to re-dis- 
placement should be overcome by placing the limb in such a 
position as shall relax the most powerful muscles connected 
with the dislocated bone, and by the application of a bandage 
to make moderate compression upon the seat of injury and 
on the implicated muscles. The disposition to inflammation, 
or this condition itself, should be combated by leeches, occa- 
sionally by general bleeding, by irrigation with cold water, 
by evaporating lotions, and by position. Warm applica- 
tions should be avoided, so long as there is any prospect of 
closing the wound by direct union. Perfect rest should be 
maintained in bed, if one of the lower extremities be involved, 
and such splints and other retentive and supporting appli- 
ances should be employed as will most conduce to the objects 
in view. 

(232) 



APPARATUS FOR RELIEF OF ANCHYLOSIS. 233 



APPARATUS FOR THE RELIEF OF PARTIAL ANCHYLOSIS. 




It not unfrequently happens after fractures involving a 
joint, dislocations, and other injuries or diseases, that the mo- 
tion of the joint is very much impaired, and the usefulness of 
the whole limb much diminished. The difficulty may often be 
entirely relieved or lessened, by adapting to the limb some 
instrument, whereby 

constant and gradu- FlG - 106 - 

ally increasing mo- 
tion may be given to 
the joint for a length 
of time. The accom- 
panying drawing (fig. 
106) exhibits an ap- 
paratus of this kind 
for the arm, which is 
recommended by Pro- 
fessor Mutter, in his 
edition of Mr. Lis- 
ton's " Lectures on 

the Operations of Surgery," &c, (p. 433, Am. edit., 1846.) 
It consists of steel splints curved to the shape of the arm and 
fore-arm, and well padded, two for the upper arm and two for 
the fore-arm, for the anterior and posterior surfaces of the 
limb. The anterior splints are connected by a steel or iron 
bar, which is firmly secured to them on each side, and jointed 
by a pivot at the centre, so as to move freely like a hinge. 
A " Stromeyer's screw" is fastened to the centre of the same 
splints in front, by moving which the apparatus may be made 
straight or angular, at pleasure. The splints are now applied 
to the limb, those for each division of the member being se- 
cured to each other by means of straps and buckles, and thus 
made to surround the arm above and below its bend, care be- 
ing had that the joint of the side bars is opposite the centre 
of motion of the elbow. When the apparatus is thus properly 
applied, the screw should be turned until the patient com- 
mences to experience slight uneasiness in the joint ; this pro- 
cess should be repeated daily, now extending and now flexing 
20* 



284 APPARATUS FOR RELIEF OF ANCHYLOSIS. 

the limb, — avoiding the infliction of pain in the joint, — until 
an adequate degree of motion is restored : the action of the 
apparatus will be very much aided by frequently soaking the 
joint in warm water. 

When so elegant a splint as that employed by Dr. Mutter 
cannot be obtained, the same effect may be had by attaching 
the screw to simple splints of wood. The apparatus may be 
adapted to the knee as well as to the elbow, and with equally 
good results. 



PART V. 

ON SOME OF THE MINOR SURGICAL OPERATIONS. 
CHAPTER I. 

ON INCISIONS. 

We cannot attach much importance to, or advise any one 
to comply with, set rules for the mode of holding and using 
cutting instruments. We believe that each can judge 
best for himself in such matters ; and that the most rational 
proposition is that each one shall use his knife in such a 
manner as will enable himself to gain, most readily and satis- 
factorily, the object which he has in view. ^Nevertheless, a 
few observations, offered as suggestions, may not be amiss 
touching the simple incisions of Minor Surgery. 

In the first place, the cutting edge of the instrument to be 
used should be sharp. And it is important that the surgeon, 
especially if he reside in the country, remote from his cutler, 
shall be able to keep his knives in good order. For this end 
he must have a proper hone; one of the " Water of Ayr''' 
stones of Scotland, or an Arkansas or Missouri stone, will 
answer the purpose. In making use of it, its surface should 
be moistened with olive oil, and the knife passed lightly over 
it from heel to point, the back being slightly raised from the 
stone, and equally, of course, on both sides of the blade. 
After the instrument has been honed until its cutting edge is 
smooth and sharp, it may be strapped, or not, as seems re- 
quisite ; but if the hone be sufficiently fine, strapping will not 
be necessary. 

Fancy has been very busy in contriving a variety of shapes 
for the simple scalpel ; the one which we have before spoken 
of, (fig. 2,) will be found as advantageous as any. It is 
usually held between the thumb and the first two, sometimes 
the first three, fingers of the right hand. If the incisions are 
to be small in extent, and require to be delicately and care- 
fully made, the knife may be held as indicated in fig. 107, 
the hand being steadied, if necessary, bv the little finger or 

(235) 



236 



ON INCISIONS. 

Fig. 107. 




•wrist resting upon the part to be operated upon. If rapid 
and extensive incisions are to be made, and if the operator 
be practised, the instrument may be best held as shown in 
fig. 108 ; but the position must be varied according to cir- 



Fig. 108. 




cumstances. For example, if the surgeon be about to sever 
rugged and partially detached portions of a flap, or to pare 
the edges of a lacerated wound, he will find it most conve- 
nient, probably, to use the knife as illustrated in the accom- 
panying drawing (fig. 109) ; if he wishes to open an abscess, 



Fig. 109. 




ON INCISIONS. 



237 



be may employ " Lyme's abscess lancet," a curved blade, 
with a sharp point and a double cutting edge, as delineated in 
fig. 110, or he may plunge a common sharp-pointed bistoury 
through the integuments, as in fig. 111. 



Fig. 110. 




The direction of the incision to-be made should depend 
upon the object to be gained. If it be desired merely to 
divide the parts, the cut is usually made in a straight line, the 
knife being entered perpendicularly to the surface, the wrist 
then depressed, and the edge of the instrument drawn along 
in contact with the skin ; when the requisite extent of divi- 
sion has been gained, the wrist should be elevated, and the 
knife withdrawn perpendicular to the skin. Or if the parts 
be loose enough, the integuments may be pinched up between 
the thumb and fore-finger, and a sharp-pointed, narrow- 
bladed bistoury, straight or curved, may be thrust through 
the base of the fold, and made to cut its way upwards at the 
same time. 



238 



ON INCISIONS. 



Fig. 112. 



A semilunar incision is sometimes performed by sweep- 
ing the edge of the knife through the skin in 
a semicircular direction. 

Sometimes it is advisable to make a crucial 
division of the soft parts, two straight incisions 
crossing each other at right angles. (Fig. 112.) 
If it be desired to remove a portion of the in- 
teguments, as in the extirpation of a considerable tumour, 
where otherwise there would be a redundancy of covering, an 

elliptical incision is made, by 
FlG * 113 - uniting two semilunar cuts at 

their extremities. (Fig. 113.) 
Judgment must be used in per- 
forming this division ; the con- 
tractility of the parts is such 
that, under ordinary circum- 
stances, the resulting wound will gape much more widely than 
the amount of tissue abstracted will account for. It is better, 
therefore, to take away too little than too much ; in the 
former event, time will diminish the difficulty, and pressure 
carefully employed will generally obviate any unpleasant 
effect ; in the latter case, the edges of the wound cannot be 
brought together, excepting by so much straining as will be 
painful, and endanger inflammation. 

Other incisions are represented in figs. 114, 115, 116, and 
117 ; names are applied to them corresponding to the letters 



Fig. 114. 



Fig. 115. 



Fig. 116. 



Fig. 117. 



which in shape they resemble. They are designed to facili- 
tate the exposure of the parts beneath the surface, the flaps 
of the integument being elevated for the time, and then re- 
placed, and their margins made to unite. 

The direction of the incision should depend somewhat, too, 
upon the situation of the part. Thus, on the face or neck, 
especially of a female, it is desirable that no unsightly scar 
should remain ; this end may be gained, to a certain extent, 



ON INCISIONS. 



239 



by dividing the skin in a line parallel to the direction of the 
fibres of the subjacent muscle. If it be advisable that the 
margins of the wound shall close readily, the skin must be 
divided in the manner just indicated : if it be preferred that 
the wound shall remain open, the incision should be more or 
less directly transverse to the course of the muscular fibres. 

It is often necessary to prolong an incision of the integu- 
ments beyond the point at which the eye can direct the in- 
strument. In such cases it is important to have a guide upon 
which the knife may be glided. For this purpose, the finger 
answers very well sometimes, as when the side of a hernial 
stricture is to be divided, the fore-finger of the left hand 
may be passed as high up as possible, and the bistoury slid in 
upon it (fig. 118,) ; or, instead of a finger, a grooved director 

Fig. US. 




may be first introduced, and the bistoury then pushed along 
its furrow, as is usually done when successive layers of tissue 
are to be divided. 

Subcutaneous wounds or incisions have, within a few years 
past, come into merited esteem, because they enable the sur- 
geon to effect even extensive division of parts without ex- 
posing them to the air, and, as a consequence, union takes 
place without inflammation and very promptly. These inci- 
sions may be accomplished thus : if the object be to divide a 
tendon, or to open a joint, a fine, sharp-pointed knife, such as 
is represented in fig. 119, must be introduced through the in- 

Fig. 119. 



240 ON INCISIONS. 

tegument, obliquely, at a little distance from the deeper point 
to be divided, and pushed on to the latter ; now the point of 
the knife should be depressed and its edge a little turned 
towards the surface to be cut, and the division of this effected 
as by stealth, to use the expression of Mr. Miller. The in- 
strument must be carefully withdrawn as it was entered, and 
the external orifice immediately closed by adhesive plaster, or 
covered with a piece of lint soaked in collodion, and perfect 
quietude of the part enjoined. A narrow-bladed knife, like 
that shown in the accompanying drawing, (fig. 120, taken 

Fig. 120. 



from Mr. Erichsen's book,) having only a part of the blade 
sharp, the remainder rounded, will answer very well for such 
sections. 

Another method of making incisions of deep-seated parts, 
so as to avoid access of air, is as follows : pinch up a fold of 
the integuments covering the part to be operated upon, and 
enter a sharp-pointed knife more or less perpendicularly at 
the base of the fold; after the desired section has been made, 
withdraw the blade carefully, and allow the integuments to 
regain their proper position, then cover the opening in the 
skin as above directed. This is a convenient mode of open- 
ing chronic abscesses, when one does not wish to evacuate all 
the matter at once. 

For more detailed instructions upon these matters, which 
we have not thought it necessary to furnish here, the reader 
may consult any good work on Operative Surgery, as Mal- 
gaigne's, Dr. Henry Smith's, or Mr. Fergusson's ; from the 
latter, particularly, we have drawn most of the illustrations 
and suggestions contained in this short chapter. 



CHAPTER II. 

ON BLOODLETTING. 

Blood may be drawn from a vein or artery of some size, 
constituting what is termed " general bleeding," or from the 
smallest vessels which ramify beneath the surface, by means 
of cups and leeches, "local bleeding." The former method 
of abstracting blood is practised when the amount to be drawn 
is considerable, or when a general depressing effect upon the 
System is desirable ; the latter, when a particular part only 
of the economy is affected, — the system generally being little, 
or not at all, involved. Sometimes, however, the indications 
for resorting to both operations exist in the same case and at 
the same time : under such circumstances, both general and 
local bloodletting should be practised, the former from a vein, 
usually, the latter from the vicinity of the suffering organ. 

In cities, these operations are generally performed by a 
class of persons who devote themselves to this duty as an oc- 
cupation. In the country, the practitioner himself must 
attend to them. Every medical man, however, should be 
well acquainted with the methods of operating, and, whether 
he live in the city, or in the country, should be skilled in the 
practice of general bleeding, at least, since he will be often 
compelled to resort to it. 



SECTION I. 
ON THE OPERATIONS FOR GENERAL BLEEDING. 

These consist in the opening of a vein or an artery ; the 
former is much the most commonly practised, and should 
always be preferred, if a choice can be made. The incision 
of a vein is termed phlebotomy; that of an artery, 
arteriotomy. 

Phlebotomy. — 1. One of the veins at the bend of the 
21 (241) 



242 



ON THE OPERATIONS 



arm is usually selected for bleeding, because these vessels are 
very superficial and convenient of access in this region, and 
are of sufficient size to allow the requisite amount of blood to 
escape freely and rapidly. The annexed drawings give a very 
good view of the veins of this region, as they are generally 
distributed, with their positions relatively to the artery and 
the superficial nerves (figs. 121 and 122). In figure 121 are 

Fig. 121. 





displayed : " 1, the radial vein ; 2, the cephalic vein ; 3, the 
anterior ulnar vein ; 4, the posterior ulnar vein ; 5, the trunk 
formed by their union ; 6, the basilic vein, piercing the deep 
fascia at 7 ; 8, the median vein ; 9, a communicating branch 
between the deep veins of the fore-arm and the upper part 
of the median vein; 10, the median cephalic vein; 11, the 
median basilic ; 12, a slight convexity of the deep fascia, 
formed by the brachial artery. This fascia is divided and 
turned aside in fig. 122, to show the brachial artery ; 13, the 
process of fascia, derived from the tendon of the biceps 
muscle, and separating the median basilic vein from the bra- 



FOR GENERAL BLEEDING. 243 

chial artery ; 14, the external cutaneous nerve, piercing the 
deep fascia and dividing into two branches which pass behind 
the median cephalic vein ; 15, the internal cutaneous nerve, 
dividing into branches which pass in front of the median 
basilic vein ; 16, the intereosto-humeral cutaneous nerve ; 17, 
the spiral cutaneous nerve, a branch of the musculo-spiral." 
Druitt, p. 494. 

The median cephalic and the median basilic veins are those 
in which the incision is generally practised in bleeding. The 
median basilic is the larger of the two, and would seem there- 
fore to be the most proper for the operation, and it is also 
more superficial than the other ; but the brachial artery is 
situated very near it, passing beneath it from the external 
side, and separated from it only by the thin aponeurosis from 
the tendon of the biceps muscle, so that an incision too deep 
would probably penetrate the artery as well as the vein, as 
has not unfrequently happened ; moreover, this vein is crossed 
in front by several filaments of the internal cutaneous nerve, 
which, as they are invisible to the operator, are liable to be 
involved in his incision. Therefore it is safer to open the 
median cephalic vein, as this is remote from the artery ; and 
as regards the liability of wounding one of the nervous fila- 
ments, the danger is rather less than in the other case, the 
external cutaneous nerve passing beneath it; the superior 
part of this vein, according to M. Lisfranc, is never crossed 
by nervous twigs. With regard to injury of the nerves in 
bleeding at the elbow, M. Velpeau says, that " all the veins 
at this part of the arm are surrounded by nervous filaments, 
and that with reference to this point, it would be ridiculous 
to open one in preference to any other." (Op. cit., p. 298.) 
Probably the best rule is, to bleed from the median cephalic 
vein, provided it is sufiiciently large to allow the blood to flow 
with freedom. If the median basilic be selected, the incision 
should be made, if possible, either above or below the point 
at which the vein crosses the artery, and not directly over 
the latter, the artery becoming more deeply situated as it 
leaves the vein. Sometimes the artery runs parallel with this 
vein ; in such cases the fore-arm should be forced into a state 
of pronation, so that the tendon of the biceps shall be made 
to intervene between the two. 

In all cases, the operator should carefully examine the part 



244 ON THE OPERATIONS 

to see that there is no anomalous distribution of the arteries, 
and to guard against danger from this cause. 

It often occurs that in females and in children, the veins 
are scarcely, if at all, visible, the adipose tissue being so 
abundant. Sometimes they may be made apparent, by allow- 
ing the ligature to compress the arm above the elbow for a 
considerable time, by plunging the fore-arm in warm water, 
by friction of the member, and by directing the patient to 
call the muscles of the hand and fore-arm into action. Gene- 
rally, however, if the veins cannot be seen, they may be felt 
beneath the surface, like round elastic cords, not pulsating as 
the artery, and losing their prominent corded form, and their 
elasticity, when the compression is removed and the blood 
permitted to flow along its channels, regaining these charac- 
teristic marks when the pressure is resumed ; the tendon of 
the biceps has been mistaken for a deep-seated vein, and has 
been cut in attempts to bleed ; such an error ought never to 
occur, as apart from the criteria above mentioned for distin- 
guishing a vein, the tendon may be easily recognized by 
flexing the fore-arm and marking the increased prominence 
which it thereby acquires. 

Before opening the vein, the surgeon should procure, and 
have arranged in some convenient position, a narrow strip of 
muslin, or linen, with which to arrest the circulation in the 
veins of the fore-arm ; a lancet ; a vessel to receive the blood 
as it flows from the incision ; a basin of water and a towel, to 
cleanse the surface after the operation ; a small compress of 
linen folded, to be placed over the wound, and a narrow ban- 
dage of muslin, or linen, to retain this in place ; smelling- 
salts, or some other restorative, should also be at hand. 

The position of the patient during the operation is a matter 
of some consequence. If it is desirable to abstract a large 
quantity of blood, the recumbent posture should be assumed, 
as syncope occurs less speedily in this than in any other 
position ; when a rapidly prostrating or relaxing effect is re- 
quired, as in cases of hernia or dislocation of the hip, the 
patient should stand up while the blood is flowing ; when an 
ordinary depletion only is indicated, and other circumstances 
permit of it, the sitting posture will be found the most con- 
venient. The size of the opening, too, should be varied in 
different cases to meet particular views ; as, for example, 



FOE, GENERAL BLEEDING. 245 

when a prompt effect is desired, the incision should be long, 
to allow the blood to escape in a full current ; a small open- 
ing should be made when a gradual influence is intended to 
be produced. 

The choice of the arm on which to practise the operation 
may be left to the surgeon's discretion ; sometimes the veins 
are larger in one arm than in the other, and their relative 
position with regard to the artery may be more favourable in 
one than in the other. If there be no reason of this kind for 
selecting the right arm, it will be better to bleed from the 
left, since, if any accident should happen, the injury is more 
easily submitted to in the latter than in the former. 

Either the thumb-lancet, or the spring-lancet, may be used 
according to the habit or the fancy of the operator ; some 
prefer one, some the other, and occasionally a patient is met 
with who has strong objections against one or the other. 
There seems to be great diversity of opinion concerning the 
comparative safety of the two instruments. It is urged in 
favour of the use of the spring-lancet, that the operation is 
done more instantaneously with it than with the other, and 
with less pain ; and that it is less frequently attended with 
wound of the artery, in those cases in which the vein is 
entered at a point directly over this vessel ; this last argument 
derives strong support from the statement of Dr. Reese, the 
American editor of Cooper's Surgical Dictionary, to the effect 
that aneurism of the brachial artery at the bend of the arm 
is much more commonly met with in the northern and eastern 
sections of this country, where the thumb-lancet is in general 
use, than in the southern and western and middle states, 
where the spring-lancet is employed very generally, and in 
many districts by very ignorant persons, as by the slaves on 
the southern plantations. The thumb-lancet is the most sur- 
gical instrument ; when of the proper shape and in perfectly 
g >od order, as it always should be, the vein may be opened 
with sufficient quickness, and with no more pain than when 
the spring-lancet is employed ; the size of the incision can be 
more nicely graduated with the former than with the latter, 
and a deep-seated vein may be more certainly reached with 
it: and as to the danger of penetrating the posterior wall of 
the vein and wounding the subjacent artery, if the thumb- 
lane t is used, the same amount of practice is as requisite to 
21* 



246 ON THE OPERATIONS 

enable the operator to determine just how far from, or how 
near to, the skin it is necessary to hold the fleam of the 
spring-lancet, in order that he may open the vein merely and 
not penetrate entirely through it, will render him capable of 
detecting, by the diminution in the resistance offered to the 
point of the thumb-lancet, the moment at which the cavity of 
the vessel has been entered by the instrument. It has occa- 
sionally happened in bleeding with the spring-lancet, that the 
fleam, or blade, of the instrument has been broken off, by the 
force of the spring, and has remained in the cavity of the 
vein, rendering it necessary in some instances to slit open the 
vessel as far as the first valve, in order to remove the lancet. 
This accident is of rare occurrence, but the possibility of such 
an incident should be borne in mind. The spring-lancet will 
be found the most convenient instrument in bleeding children, 
in consequence of the struggles which they usually make, and 
which interfere very much with the performance of the opera 
tion when the thumb-lancet is used. 

The shape of the blade varies very much according to the 
fancy of the surgeon, or of his cutler; we would recommend 
one rather more oval-shaped at the point than that repre- 
sented in fig. 123. The point and the edges of the instru- 
ment should be very sharp, and the blade as thin as is com- 
patible with perfect strength and security. The lancet used 
for bleeding should never be employed for any other pur- 
pose, as cases have often occurred of inoculation of the 
wound with irritating or poisonous matters which have ad- 
hered to the blade. The instrument should be well cleansed 
and wiped dry after it has been in requisition, and kept in a 
suitable case. 

Operation. — The operation is commenced by encircling 
the arm, at a point an inch or two above the elbow, by a 
piece of ribbon, or a strip of muslin, an inch and a half wide 
and a yard and a half long. The arm should be bared 
nearly to the shoulder, care being had that the sleeve of the 
patient's dress exercises no constriction about the limb, im- 
peding the flow of the blood through the artery ; then the 
surgeon, having carefully examined the bend of the arm, in 
order to ascertain the precise position of the brachial artery, 
and whether there be any anomalous distribution of the ves- 
sels, places the centre of the compressing bandage upon the 



FOR GENERAL BLEEDING. 247 

middle of the arm, at the point already indicated, carrying 
the tails around on each side successively, and bringing them 
up over the anterior face of the arm, to tie them in a single 
bow-knot on its outer side, the extremities of the band hang- 
ing downwards. The bandage should be applied sufficiently 
ti* T ht to arrest the course of the blood in the superficial veins, 
but not to interfere with the circulation in the artery. If, as 
is sometimes the case, the veins do not swell, the expedients 
before adverted to should be tried, and if these are ineffectual, 
the other arm should be taken, or a vein in some other part 
of the body may be opened, if it should be impossible to find 
a suitable vein in either arm. In such circumstances, M. Lis- 
franc advises that the cephalic vein should be exposed, where 
it occupies the interstice between the deltoid and pectoralis- 
major muscles, and an incision made in it. But there are 
few instances in which it is not possible to abstract the requi- 
site amount of blood from one of the veins at the bend of the 
arm. The vein having been selected for the operation, and 
the exact situation of the artery with reference to it ascer- 
tained, the next step is to make the incision. It is of great im- 
portance that the patient's arm shall be well secured, in order 
to avoid any accident which might ensue from a sudden 
movement of the limb, as the instrument pierces the tissues ; 
thi3 is of less moment when the spring-lancet is employed, 
than if the thumb-lancet is used. When the latter instru- 
ment is selected, the operator will find it of much advantage 
to be equally skilful w T ith his right and left hands, as he can 
secure the patient's arm, and perform the operation more 
satisfactorily. Thus, the arm should be thrown out from the 
body, and the surgeon should sit, or stand, between the limb 
and the side of the patient : if the right arm is to be operated 
upon, the elbow should be supported upon the outstretched 
fingers of the surgeon's left hand, his thumb pressing upon 
the vein, about an inch below the point of incision, in order 
to steady the vessel, and to prevent a too great out-gush of 
blood from soiling the clothes, while the patient's fore-arm 
and hand are extended beneath the left fore-arm of the ope- 
rator, and thus securely held ; the lancet is, of course, entered 
with the right hand : if a vein of the left arm is to be opened, 
the surgeon modifies his position, so as to secure the arm with 
his own right hand and arm, and holds the instrument in his 



248 



ON UHE operations 




left hand. But if, as is the case with most persons, the ope- 
rator cannot make the incision conveniently with his left hand, 
he must place himself on the outer side of the patient's left 
arm, securing the fore-arm with his own left, and open the 
vein with his right hand. 

The blade of the lancet should be exposed so as to form 

a slightly obtuse angle 
Tig. 123. with the handles, and 

held as is represented 
in the annexed drawing, 
(fig. 123,) being grasped 
near its head between 
the extremities of the 
surgeon's thumb and 
fore-finger, the handle 
resting against the lat- 
ter. The operator places 
his middle finger upon the patient's fore-arm, as in the figure, 
so as to support the hand : the point of the lancet is entered 
perpendicularly to the surface, if the vein is deep-seated, but 
at a more obtuse angle if the vessel is more superficial ; the 
mere straightening of the thumb and fore-finger serves to 
force the point of the instrument through the integuments 
and the anterior wall of the vein, when, so soon as the escape 
of blood and the cessation of resistance to the entrance of 
the blade make the surgeon aware that the point is within 
the cavity of the vessel, he depresses the handle of the instru- 
ment, and at the same time pushes it a little forwards by his 
thumb and fore-finger, until the incision has been made suf- 
ficiently long, when the blade is withdrawn ; or it is perhaps 
safer to force the blade to cut its way out of the vein, so soon 
as the latter has been entered, by depressing the handle 
more and more, thus bringing the cutting edge in contact 
with the anterior wall of the vessel and with the integuments, 
successively : in this way there can be but little danger of 
penetrating the posterior coats of the vein with the point of 
the lancet. The incision should generally be somewhat oblique 
with regard to the axis of the vein, especially if the vessel 
be of small calibre, as otherwise the blood will escape more 
slowly. 

If the spring-lancet is used, it should be held more or less 



FOR GENERAL BLEEDING. 249 

obliquely to the course of the vein, according as the vessel is 
of small or large calibre : when the vein to be opened is su- 
perficial, the point of the blade should be held a little above 
the skin, so that it shall simply enter the vessel, and not pierce 
entirely through it ; if, on the contrary, the vein is more deeply 
seated, the point of the fleam should rest upon the surface. 
In bleeding from a vein which is directly over the artery, the 
incision should be made upon the side of the vessel, instead of 
its anterior face, as being less liable to penetrate to the ar- 
tery itself. 

If, after the incision has been made, the blood does not flow 
freely, the patient may be directed to grasp something in his 
hand, as a cane, closing and relaxing his fingers upon it al- 
ternately, thus compressing, by the contraction of the mus- 
cles, the deep veins, and forcing the blood into the more su- 
perficial channels; the current through the vein is sometimes 
impeded by a constriction of the artery, arising from the too 
tight application of the bandage, which should of course be 
loosened : again, it may occasionally happen that a shred of 
adipose tissue may obtrude itself across the incision, and thus 
obstruct the escape of the blood ; the remedy for this difficulty 
will at once suggest itself to the operator. Syncope, accom- 
panied by cessation of the flow, is at times produced by the 
dread of the operation which some persons experience, or by 
the sensation of the incision itself, or by the sight of the blood, 
in very sensitive patients ; in such instances, smelling-salts 
should be applied to the nostrils, cold water be dashed upon 
the face, and the individual be placed in the recumbent posi- 
tion, until the faintness shall have passed off, when the blood 
will flow again, generally. 

It is of little consequence what kind of vessel is employed 
to receive the blood as it escapes from the vein ; a common 
bowl answers the purpose as well as any other: however, if it 
be desirable to fix precisely the amount to be abstracted, the 
44 bleeding-cup" proper should be used, — a vessel having lines 
upon its inner side graduated to show the number of fluid- 
ounces which it may contain : such bowls may be had of most 
of the druggists. 

After the required amount of blood has been drawn, the 
bandage should be removed from the arm ; the edges of the in- 
cision approximated by the thumb and forefinger of the sur- 



250 ON THE OPERATIONS 

geon's left hand; the surface cleansed; the compress placed 
upon the wound, and retained in this position by the crossed 
bandage, as shown in figure 18. In applying the bandage, 
care should be had that it does not compress the arm above 
the opening in the vein more than below this point, otherwise 
the blood may again flow from the incision. After the lapse 
of twenty-four hours, during which time the patient should 
keep the elbow flexed, and avoid using the arm, — the bandage 
may be removed, as in most cases the orifice will have become 
sufficiently closed to prevent the escape of the blood. 

If it be probable that it will be expedient to repeat the 
bleeding in the course of twenty-four hours, the necessity of 
opening another vein may be avoided by anointing the com- 
press with fresh lard, so that the orifice made in the vein will 
close less speedily than when a dry compress is applied. It 
is requisite merely to remove the bandage and encircle the 
arm, just above the elbow, with a band, as in the first bleed- 
ing : if the blood does not escape, on the vein becoming tur- 
gid, the hand should be passed upwards along the vessel, when 
the fluid will generally burst through the imperfectly closed 
incision ; if it do not, a fine probe may be used to re-open the 
wound. 

2. Bleeding from the hand. 

Operation. — Compress the fore-arm by a circular bandage 
applied just above the wrist, in order to render turgid the 
veins upon the back of the hand, and make an incision with 
a thumb-lancet into the largest of these vessels, in the same 
way as has been directed above with respect to the veins at 
the bend of the arm. The cephalic vein, formed by roots com- 
ing from about the thumb and fore-finger, and the vena salva- 
tella, from the other fingers, are the largest trunks. Care is 
necessary that the incision be not made so deep as to perfo- 
rate the vein and wound the subjacent tendons. 

The wound, after the bleeding, should be covered as in the 
last-described operation. 

3. Bleeding from the ankle. 

Operation. — Plunge the foot in a basin of warm water, 
and allow it to remain until the veins running along the ankle 
shall have become swollen ; then remove the foot from the 
water, dry it, pass a circular bandage around the leg just 
above the malleoli, and open the internal saphena vein near 



FOR GENERAL BLEEDING. 251 

the inner ankle, the vessel being fixed by the thumb of the 
left hand, placed just below the point of the intended incision. 
The opening should be oblique, and rather longer than is re- 
quired for the veins of the fore-arm, so that the blood may 
have every facility for its free escape. After the incision, if 
the current do not flow readily, the foot should be again placed 
in the water, in which case the amount drawn must be judged 
of by the discoloration of the water, or by the effect produced 
upon the patient. 

The operator should be careful to regulate the force w T ith 
which he makes the incision according to the volume of the 
vein ; otherwise, by penetrating too deeply, he incurs the lia- 
bility of breaking the point of his lancet against the bone. 
The thumb-lancet should be used. The external saphena vein 
is sometimes opened at the outer ankle, but it is rarely so 
large as the other. The operation is performed as on the in- 
ternal saphena. 

The requisite amount of blood having been removed from 
the vessel, a small compress should be placed upon the inci- 
sion, the surface cleansed, and a figure-8 bandage applied to 
retain the compress, circling around the leg and the foot, above 
and below the ankles, leaving the heel exposed, and crossing 
upon the instep. 

4. Bleeding from the external jugular. 

This operation is rarely performed, partly in consequence 
of the more or less danger attending it, but chiefly because 
the required amount of blood can generally be taken from a 
vein at the elbow. It is sometimes advisable, however, to 
practise this operation ; as, for instance, in convulsions occur- 
ring in young children, in whom there is frequently much diffi- 
culty in bleeding from the arm ; also in apoplectic seizures. 

When it is determined to open the external jugular, the in- 
cision is usually made between the lower third of the vein and 
a point two inches above the clavicle. Below this point, there 
may be danger that the air will enter through the orifice to 
the heart, thus causing almost instant death. Above its lower 
third, the vein is so surrounded by nervous filaments that the 
incision of the former would, very probably, implicate the 
latter. 

Operation. — The patient is placed in a sitting, or in the 
recumbent, posture ; a thick compress should be laid upon the 



252 



ON THE OPERATIONS 



vein in the supra-clavicular fossa, and retained in this position 
by a strip of muslin, or a cravat, which crosses the chest ob- 
liquely from this point to the axilla of the opposite side, where 
its tails are united, as in the accompanying drawing (fig. 124.) 



Fig. 124. 




In opening the vein, the surgeon places the thumb of his left 
hand upon the compress, and his forefinger upon the swollen 
vein, just above the point selected for the incision, and opens 
the vessel pretty freely in a line obliquely upwards and out- 
wards, crossing the fibres of the platysma-myoid, so that the 
lips of the wound may be w r ell separated. A tea-cup, or a 
small bleeding-bowl, should be held against the skin at the 
lower edge of the opening in the vein, to receive the blood as 



FOR GENERAL BLEEDING. 253 

it escapes : or if the current do not jet from the orifice, a card 
should be bent to the form of a gutter, or trough, to convey 
the fluid into the cup. The compression should not be inter- 
mitted until the operation is completed, and the opening in 
the vein closed by another compress placed upon the wound : 
this precaution is intended to prevent the ingress of air. The 
compress may be retained in place by short strips of adhesive 
plaster laid across it. or by the circular bandage of the neck, 
described under the head of regional bandages. 

The escape of the blood may be facilitated, if it do not 
flow readily, by directing the patient to move the lower jaw, 
as in masticating. After the operation, difficulty is occa- 
sionally experienced in arresting the flow ; under such cir- 
cumstances the recumbent posture should be maintained, all 
compression from clothes carefully removed, and the patient 
be directed to breathe freely and fully. M. Magistel closes 
the wound, in such cases, with a fine suture. 



ACCIDENTS ATTENDING PHLEBOTOMY. 

Fortunately these are rare, when the frequency of the 
operation is considered, and those which occur most frequently 
are so slight in themselves and in their consequences, as 
hardly to merit the appellation of accidents ; such are the 
formation of what is termed a thrombus, and syncope partial 
or complete. The proper remedies for the latter have been 
mentioned, in treating of bleeding from the arm. A thrombus 
is a tumour, or swelling, generally of small size, produced by 
the infiltration of blood into the cellular tissue surrounding 
the vein. It is owing, in most cases, to the external incision 
not corresponding exactly in situation with the opening in the 
vein, the correspondence having become destroyed by some 
movement of the arm, or by a want of attention on the part 
of the operator, while making the incision, to have the skin 
tense and smooth ; any cause which will obstruct the ready 
escape of the blood from the vein to the external surface may 
develope a thrombus. Generally it is a matter of little con- 
sequence, giving rise only to some swelling, discoloration, and 
stiffness at the elbow, which inconveniences will disappear in 
a few davs. Sometimes, however, if the effusion is large, the 
22 



i 



254 ON THE OPERATIONS 

fluid is removed by suppuration instead of by absorption, and 
there is danger that the vein will become involved in the 
inflammation. 

The simpler cases of this incident to bleeding require very 
slight treatment ; the removal of the effusion will be hastened 
by keeping the arm at rest and covering the affected part 
with soap-plaster, or a wash of diluted spirits of camphor, or 
of some similar resolvent. If inflammation and suppuration 
occur in the tumour, a splint should be confined upon the 
back of the arm and fore-arm, to maintain perfect repose of 
the tissues about the elbow, and leeches, cold lotions, irriga- 
tion, or poultices, should be made use of, according to the 
condition of the tumour. 

By carefully watching the escape of the blood during the 
operation, the surgeon may often guard against, or arrest, the 
formation of a thrombus, by maintaining the parallelism be- 
tween the wound in the integuments and that in the vein, or 
by restoring this condition if it has been deranged. If this 
correspondence cannot be regained, and the tumour increases 
in size, the external incision should be enlarged sufficiently 
to permit of the blood reaching it, or another vein should be 
opened. 

Wound of a Nerve. — This accident may happen, and it 
has occurred to the most skilful operators in bleeding, and it 
cannot be considered as a subject of reproach. It will be re- 
cognised by some disturbance in the functions of the part to 
which the nerve is distributed. If the wounded nerve be a 
nerve of sensation, pain will be experienced at the seat of the 
incision, or at the terminal ramifications of the nerve, a sen- 
sation of numbness or of tingling, or the skin will be deprived 
of sensibility. If it be a motor nerve which has been impli- 
cated in the incision, the muscle, or muscles, to which it gives 
power will be more or less paralysed, or be the seat of irregu- 
lar motor action, spasmodic twitches, tetanic rigidity, and the 
like. 

This accident is a much more serious one than those already 
considered, and should be so regarded. The treatment con- 
sists in the application of antiphlogistic or anodyne remedies 
to the surface, according to the symptoms ; in securing the 
limb to a splint in a semiflexed position, and in the adminis- 
tration of opiates internally. The limb should be kept in a 



FOR GENERAL BLEEDING. 255 

state of perfect rest on a splint, for two or three weeks, or so 
long as there is any probability of the reunion of the cut 
extremities of the nerve, experiments and observations having 
shown that restoration of the functions of nerves simply 
divided does take place. (Carpenter's Human Physiol. ; 
Muller's Physiol, vol. i. p. 457, &c.) 

Wound of an Artery. — The brachial artery is the one 
most liable to be wounded in phlebotomy, and its accidental 
puncture may be taken as a type of similar injuries of other 
arteries. The signs usually mentioned as indicative of this 
accident are, the flowing of the blood in jets from the external 
opening, and the bright-red hue of the fluid. These appear- 
ances, however, are fallacious, for venous blood is not always 
of a dark blue colour ; in fact, in many persons and in some 
diseases, its colour approaches very nearly to the hue of arte- 
rial blood ; and if the vein which has been opened is seated 
immediately upon the brachial artery, the pulsations of this 
vessel will often agitate the vein, and communicate a jetting 
motion to the current as it escapes from the latter. The 
occurrence of the accident may be recognised pretty surely, 
by observing whether the blood continues to flow from the 
external wound, when the vein is compressed at the lower 
edge of the incision ; if such is the case, the artery has pro- 
bably been opened, the only circumstance likely to mislead 
the observer arising from the communication of another vein 
with the one in which the aperture has been made, opposite 
the orifice ; this must be a very unusual incident. Additional 
knowledge may be acquired as to the non-existence of injury 
to the artery, by compressing this vessel at some point above 
the wound, when, if the colour of the blood remain as before, 
the inference from this fact, conjoined with the cessation of 
the flow when the vein is compressed below the orifice, while 
the artery still pulsates at the wrist, is, that only the vein has 
been opened. Again, if the external wound be closed with 
sufficient force to compress the vein merely without obliter- 
ating the artery, a gradually increasing tumour will be devel- 
oped in the tissues, if the artery has been punctured. The 
existence of the injury having been ascertained, there can 
still be no impropriety in permitting the blood to escape until 
the amount originally intended to be drawn has been removed. 
Then the surgeon must determine whether it is better, in the 



256 



ON THE OPERATIONS 



particular instance, to endeavour to remedy the accident by 
the long-continued employment of a compress and bandage, 
or to obliterate the artery at once by the application of a 
ligature, or ligatures. M. Velpeau recommends that the first 
method be tried for a week or two, unless some serious 
appearance present itself. (Velpeau, op. cit. p. 312.) This 
course having been determined upon, a graduated compress 
should be formed, of a pyramidal shape, and applied with its 
apex upon the wound, a figure-8 bandage being made to retain 
it in place with a degree of compressive force considerably 
greater than would be sufficient to obliterate the vein merely, 
so that the pulsation at the wrist shall be arrested (fig. 125) ; 
the limb, from the fingers to the axilla, should be enveloped 
carefully in a roller-bandage, and maintained in a state of 
perfect rest upon a splint, in the straight position ; the patient 
should remain in bed, or his arm should be supported in a 
sling. If, after compression has been employed, the forma- 
tion of an aneurism be detected, the treatment necessary for 

Fig. 125. 




Plan of a Graduated Compress. — a, the artery wounded ; b, b, the 
graduated compress arranged so that the apex of the cone is in immediate^ 
contact with the arterial orifice, while its mass occupies the general wound, 
and projects somewhat above the integumental level. 



this affection must be adopted ; for this, and for the best 
method of obliterating the artery by ligature, if the treatment 
by compression be rejected at first, the reader is referred to 
treatises on practical surgery. 

Wounding of the Tendon of the Biceps, or of other 
Muscles. — It happens occasionally that one of the tendons 
is pricked by the point of the lancet, when it is seated beneath 
the vein which has been opened ; or the operator may have 
mistaken the tendon for the vein, and plunged his lancet 
therein. Some degree of pain and difficulty in using the 



E R GENERAL BLEEDING. 257 

muscle are generally experienced, after such an accident, but 
the symptoms are rarely of a violent character. The treat- 
ment consists in keeping the limb at rest upon a splint, the 
muscle being relaxed, and in the application of anodyne and 
emollient remedies. In irritable patients, it may be advisable 
to abstract blood from the part, by leeches, and to administer 
opiates. 

ARTERIOTOMY. 

The temporal artery is the only one upon which this ope- 
ration is now practised, and very rarely is it considered 
advisable, even on this vessel. The artery is superficial, is 
favourably situated for compression after the operation, and 
is generally large enough to allow of the abstraction of a 
sufficient amount of blood. Although the incision of the 
vessel is one of the simplest of operations, it is sometimes 
followed by the development of an aneurism. 

A strong lancet, or a bistoury, — a graduated compress, — a 
narrow roller, two or three yards long, — warm water and a 
towel, are all that are usually needed for the operation. 

The trunk of the temporal artery itself, or its anterior 
branch, may be opened ; if the former, the mode recom- 
mended by M. Magistel may be resorted to, as follows : — 
The position of the trunk is ascertained at the point where it 
is most superficial, and where its pulsation is most forcible, 
and there marked with ink in the direction of the intended 
incision : this point will be found a little in advance of the 
ear, and above the zygomatic arch. The patient may sit up, 
or assume the recumbent position, his head resting upon a 
pillow on the opposite temple ; the surgeon steadies the 
artery by one finger placed upon the surface, on the outside 
of the vessel, and about a quarter of an inch above the site 
of the intended incision ; the bistoury is held as the lancet in 
phlebotomy, and entered through the integuments on the 
inner side of the artery, cutting its way obliquely through 
the vessel and the integuments of the opposite side. The 
blood is received directly in a cup, or it is guided to the 
latter through a little gutter of paper, placed against the sur- 
face beneath the opening : a plug of cotton should be inserted 
into the chamber of the external ear, to prevent the blood 
22* 



258 ON TOPICAL BLEEDING. 

from entering it. When the proper amount has been drawn, 
the flow is generally easily arrested by placing a small com- 
press of folded linen upon the orifice, (its lips having been 
placed in apposition,) and securing it thus by a few circular 
turns of a roller. If this be insufficient to stop the bleeding, 
a fine suture may be passed through the edges of the wound. 
(Malgaigne, Med. Op£rat.) 

If the blood do not flow freely, the patient, if he be con- 
scious, should be requested to move his jaw, as in mastica- 
tion, or a sponge filled with warm water may be laid upon the 
vessel. 

M. Velpeau advises that one of the branches of the artery 
be selected for the operation, particularly the anterior 
branch in its course towards the forehead, as it is very super- 
ficial, and reposes so nearly upon the bone, that a firm com- 
pression may be made upon it. The mode of performing the 
operation is the same as for the trunk itself: the lancet may 
be used as in opening a vein, or a bistoury may be employed, 
and the integuments and vessel divided, from the former 
towards the latter, and from the outer side of the artery 
towards the operator. See fig. 124. 



SECTION II. 
ON TOPICAL BLEEDING. 

1. On the application of the cupping apparatus. 

In professional language, "a cup" is a small, bell-shaped 
vessel, made of glass, or thin metal, intended for application 
to the surface of the body, with the view either of removing 
a certain amount of blood from the minute veins and arteries 
which have been previously incised, or of merely producing a 
congestion of the surface, or a certain degree of ecchymosis. 
The first is termed "wet-cupping," or simply "cupping," the 
latter " dry-cupping." 

Dry cupping is effected by merely acting upon the air 
within the cup, so that the integuments, on the surface of 
which it is placed, shall be forced, by the pressure of the 
atmosphere without, into the partial vacuum formed within 
the vessel. This vacuum may be produced in several differ- 



ON TOPICAL BLEEDING. 259 

ent ways, either by means of heat so applied as to rarefy the 
air within the enclosure, or by the direct abstraction of a cer- 
tain portion of it through the aid of a pump. The latter is 
the most convenient and the most eligible mode. The pump 
is made to fit upon the summit of the cup, which is perforated 
with a small hole covered with a thin valve of oil-silk, or 
of gum-elastic, to exclude the entrance of air from without ; 
while, by the action of the pump, a very considerable ex- 
haustion can be effected within the cup. The cup is best 
made of glass, so that the degree of turgescence of the inte- 
guments can be seen ; when this is deemed sufficient, the 
glass is easily detached from the surface by slightly raising 
the valve by means of a pin inserted beneath it, when the 
pressure of the atmosphere within and without the cup will 
become equalized. 

If this complete cupping apparatus be not at command, the 
operation may be sufficiently well performed by using a com- 
mon wine-glass, or tumbler. The vessel may be immersed in 
hot water, in order to heat its surface, and then, before it 
becomes cooled, applied upon the skin ; thus the air which it 
contains becomes rarefied by the heat of the material of 
which the cupping vessel is composed, and retreats before the 
ascent of the integuments, which are pressed upwards by the 
weight of the air surrounding the cup ; or the inner surface of 
the cup may be moistened with spirits of wine, which should 
then be inflamed, and while the vessel is yet warm, it should 
be placed upon the skin ; or, finally, small pellets of cotton,- 
or strips of paper, may be moistened with the same fluid, then 
lighted and introduced into the cup, which is used as above. 
The vessel may be loosened from the surface after a proper 
time, by pressing upon the integuments at its edge, so that 
the air may rush into the cavity. 

Dry cupping will be found of great benefit in the relief of 
internal congestions, when it is not expedient to abstract 
blood. It seems not to produce its good effect by revulsion 
merely, or by the external irritation which it causes, but also 
by rendering the vessels on the surface turgid, producing a 
true ecchymosis, and thereby diminishing temporarily the 
amount of fluid in circulation through the vessels. 

Wet cupping requires that, in addition to the local tur- 
gescence which the dry cupping occasions, the surface thus 



260 ON TOPICAL BLEEDING. 

engorged shall be incised, its small vessels opened, and blood 
be abstracted therefrom. To accomplish this object, the cup- 
ping apparatus must be used as above described, and after 
the integuments have become sufficiently full of blood, the 
cup should be removed and a number of incisions made on 
the surface, deep enough to open the subcutaneous vessels ; 
then the cup is to be re-applied, and the air again exhausted 
from it ; thus the blood will flow readily from the openings 
made. After a sufficient amount has been obtained, the cup 
is removed and the surface cleansed ; generally, no dressing 
is called for, but if there be much smarting, cold or warm 
water, or a piece of linen spread with simple cerate, may be 
applied, as may be most agreeable to the patient. In direct- 
ing the use of cups, it is generally considered that each one 
will draw one ounce of blood ; this is not strictly correct, as 
the amount will vary very much, according to the vascularity 
of the part to which the application is made ; sometimes a 
single cup will abstract several ounces if re-applied to the 
same spot, and again but a very small proportion of this 
amount can be taken. The flow of blood may be encouraged 
by immersing the cup, before it is placed upon the skin, in 
warm water, and by laying a sponge or towels dipped in warm 
water upon the surface, while the cup is acting. The depth 
of the incision must be regulated to suit the character of the 
surface ; where the integuments are thick, containing much 
adipose tissue, the incisions must be deeper than under oppo- 
site circumstances. The proper instrument for making the 
incisions in cupping is the "scarificator," — a metallic box of 
about the same size as the cup, having its interior surface 
pierced with a number of slits, through each of which a lancet- 
blade is made to protrude by means of a spring, the frame 
upon which the blades are secured being elevated or depressed, 
so as to regulate the depth of the incisions, by the turning of 
a screw arranged for the purpose. In the absence of this sca- 
rificator, the necessary incisions may be made by a scalpel, or 
a thumb-lancet ; they may be parallel to each other, or crossed, 
or have an oblique direction. 

The operation of cupping is sometimes a painful one, par- 
ticularly upon surfaces not very well cushioned by integu- 
ment, as on the chest of thin persons, and also when performed 
over inflamed cavities, as upon the abdomen in gastritis, en- 



ON TOPICAL BLEEDING. 261 

teritis, or peritonitis ; but even in these latter cases, the ope- 
ration may be effected with comparatively little pain, by first 
applying a poultice, or a fomentation, upon the surface ; thus 
the sensibility of the part becomes lessened. This is a 
matter of considerable consequence, as leeches cannot always 
be obtained in all situations ; and by the simple precaution 
just stated, cups may be very well used instead, in numerous 
instances in which, otherwise, the advantages of local deple- 
tion must be foregone. 

It is of importance to bear in mind that the benefit of 
cupping does not consist in the local abstraction of blood 
merely, but also in the stimulation which it effects upon the 
surface to which the cups are applied, and in the revulsive 
action which is thereby occasioned. 

2. On the employment of leeches. 

There are many cases demanding local depletion, in which, 
from peculiarity of situation, or excessive sensitiveness of 
the surface, cups cannot be employed ; in such instances, 
leeches may be used, as also in all other conditions requiring 
the topical abstraction of blood. 

Previous to the application of the leech, the surface on 
which it is to be placed should be cleansed with warm water, 
so as to remove, as far as possible, any matter which may 
adhere to the skin, either as the result of medicinal applica- 
tions, or as incident to the natural or diseased processes going 
on in the part : if this precaution be not taken, much diffi- 
culty and delay will be experienced in inducing the leech to 
fasten upon the surface, and the animal itself may be injured 
or killed, by the introduction into his system of such noxious 
matter. If the surface to be leeched be covered at all thickly 
with hair, as the pubis, the scalp, &c, it should be shaved 
before the leech is applied to it. When a number of leeches 
are to be applied to a circumscribed part, it is often found 
difficult to confine them within a sufficiently restricted range, 
if they are simply placed on the surface ; this may be over- 
come by moistening the skin, at different points, w T ith blood 
drawn from the tip of the finger, or with sugar and water ; 
or the leeches, as many as are intended to be employed, may 
be put into a tumbler, or wineglass, which should then be in- 
verted upon the skin ; or, finally, the palm of the hand may 
be covered with a napkin, and the leeches placed upon the 



262 ON TOPICAL BLEEDING. 

latter, and thus held against tfe surface until they shall have 
attached themselves. When blood is to be taken from the 
mucous membrane lining a canal, it is necessary to place the 
leech in a tube, which is then to be introduced into the canal, 
its open extremity applied to the membrane at the proper 
point, and there retained until the leech has fastened itself 
upon the surface. Thus if the depletion is to be effected 
from the neck of the uterus, the neck of the bladder, or from 
any part of the vagina, in the female, — a speculum of polished 
metal, made of a single piece, and having the upper end cut 
obliquely, should be introduced into this passage to the proper 
distance, the polished internal face of the speculum enabling 
the operator to see each point of the vagina ; the leeches are 
now to be placed in the speculum, and thrust up to the affected 
spot by means of a quill, or a stick. For the rectum, a smaller 
speculum is required. For the nostrils, a tube of glass slightly 
curved at its upper extremity, and about a quarter of an inch 
in diameter, gradually tapering downwards towards the curve, 
may be used; this should be introduced, and the point of the 
curvature carried opposite the spot upon which the leech is to 
be attached ; the animal is then to be placed in the cavity, 
and pushed upwards by means of a quill, or a pencil ; as soon 
as it has fastened upon the membrane, the tube may be with- 
drawn, and, if necessary, another leech introduced in the 
same way. A similar plan should be adopted in the applica- 
tion of leeches to the gums, or to the lining membrane of the 
mouth at other points. 

If, accidentally, one or more of these animals should 
escape beyond the reach of the operator, as into the stomach 
or rectum, it may be destroyed by injecting a solution of salt 
into the cavity ; afterwards the leech will be discharged dead. 

Repletion causes the leech to fall from the surface upon 
which it had fastened ; but if it be expedient to detach it 
before it has become filled, fine salt should be placed upon it ; 
it should not be violently pulled from its hold upon the skin, 
lest a portion of its mouth remain in the little wound which 
it has made, causing more or less irritation and destroying 
the animal. 

The quantity of blood which a leech will draw varies very 
much with the kind of leech used, and the degree of vascu- 
larity of the surface. Six of the ordinary American leeches 



ON TOPICAL BLEEDING. 263 

are allowed for each ounce of blood required ; these answer 
very well for application to the external surface, in situations 
possessing an average condition of the circulation, and offer- 
ing space sufficient to allow of the application of the requi- 
site number ; their bite is less irritating and less deep than 
that of the European leech, and hence they should always be 
employed upon children, and upon others w T hose skin is prone 
to a morbid degree of inflammation or soreness, from slight 
causes. An ounce of blood is generally allotted, as the 
capacity of two or three Swedish, or Spanish, leeches. These 
are used when the part to be depleted is endowed with little 
vascularity, and upon internal surfaces of which the secre- 
tions are naturally, or from disease, more or less acrid or 
offensive to the animal, as the mucous membrane of the vagina, 
that covering the neck of the uterus, the rectum, the gums; 
and it is advisable always, before applying the leech to such 
parts, to wash them with warm water. 

After the animal has fallen off, the blood continues to flow 
from the w r ound, but this ceases in the course of a few minutes, 
if the bite be left exposed to the air, unless a small arterial 
branch of notable size has been opened. If a sufficient de- 
pletion has been had, and the bleeding does not cease of 
itself, cold water should be laid upon the surface, or dry lint ; 
and if anything more effectual is necessary, pressure with the 
finger, a little fine lint intervening between its point and the 
leech-bite, may be made upon the latter for a few minutes, 
and then the finger gently withdrawn, leaving the lint behind ; 
this will generally be sufficient to arrest the bleeding ; but if 
this fail, a fine point of lunar-caustic should be thrust into 
each bleeding wound, and quickly removed; finally, it is re- 
commended, in obstinate cases of such hemorrhage, to pass a 
fine needle transversely through the lips of the wound, and 
to lay upon it a twisted suture ; this, however, must be very 
seldom required. 

If it be deemed expedient to encourage the flowing of the 
blood, warm water should be laid upon the part, or a warm 
poultice. 

The preservation of the leech is a matter of great import- 
ance. To insure this object, the habits of the animal should 
be ascertained, in order that it may be placed in circumstan- 
ces in which these habits and instincts may still be indulged. 



264 ON TOPICAL BLEEDING. 

It should be kept in some suitable vessel, — an ordinary tub 
will answer, — containing water, and pieces of turf, or, which 
is still better, of peat, into which the animal may insinuate 
itself, and, by the friction of its surface against the interlaced 
roots of which the peat is composed, cleanse itself of the 
slimy secretion which covers it, and which, if permitted to 
remain long upon the exterior, prevents the proper perform- 
ance of certain functions on which the health of the leech 
depends. The water moreover should be changed as often as 
once every w T eek, and the leeches should be washed, unless 
they have the means, as above described, of performing this 
office for themselves. The animal obtains its supply of oxygen 
from the air entangled in the water, and not by rising to the 
surface to breathe. 

In this w T ay leeches may be preserved for an indefinite 
length of time, until needed for application ; but after they 
have been once employed in drawing blood, they never are so 
efficacious again. If they have been applied to abstract blood 
from persons suffering from some malignant or contagious 
disease, they should not be used subsequently. 

The natural food of the leech consists of smaller aquatic 
animals which it meets with in its native haunts; and the 
admirable apparatus with which it is provided, and which 
adapts it so perfectly to the purpose to which it is made 
subservient in the treatment of disease, would seem to be 
contrived for the especial benefit of man, - — to be, in a mea- 
sure, an appendix to the animal, and not called for in the 
operations of its own economy. Hence, although the blood 
with which it fills itself to distension, in the gratification of its 
voracious thirst, does not putrefy in the animal's stomach, 
notwithstanding the length of time during which it will be 
retained in this cavity, unless it be evacuated artificially, — in 
most cases, the animal will die unless the blood be removed 
from it. (T. Rymer Jones's Comparative Anatomy.) To 
accomplish this, it is requisite merely to place some fine salt, 
or salt water, upon the leech, which will cause the animal to 
eject the contents of its stomach by the mouth. The author 
is informed by Mr. Moore, who is one of the best leechers in 
this city, that he effects the removal of the blood by making 
one or two small punctures on the back of the leech, on each 
eide of the middle line ; the contents of the stomach and of 



ON TOPICAL BLEEDING. 265 

the numerous sacciform appendages to this central cavity are 
evacuated through these punctures, which soon close again 
without having injured the animal at all. Mr. Moore prefers 
this method to the use of salt, which he thinks is in some 
measure hurtful to the leech. Leeches which have thus been 
emptied of the blood that they have drawn, should be placed 
in a vessel containing water and turf, as above mentioned, 
and kept distinct from others for two or three weeks, after 
which they may again be employed. 

Within a few years past, " artificial leeches" as they are 
called, have been introduced. These are small tube-shaped 
cupping-glasses ; their diminutive size permits them to be 
applied where the ordinary cupping-glass could not be placed. 
They are not comparable to leeches as a means of abstracting 
blood from certain parts ; but they may prove serviceable 
under circumstances when leeches cannot be procured. 

Simple scarification of the surface with a lancet or scalpel, 
is sometimes resorted to as a means of local depletion. It 
can only be employed on very vascular parts, as on the 
tongue, the mucous membrane lining the interior of the 
mouth, and that covering the fauces and the eyelids. 



23 



CHAPTER III. 

ON THE DIFFERENT MODES OF EFFECTING CUTANEOUS 
IRRITATION. 

It has long been an established principle in medicine, that 
■when a point of irritation exists in any part of the body, there 
will be a corresponding accumulation at that point of organic 
energy and of circulating blood ; and the physical and chemi- 
cal changes which accompany every manifestation of organic 
action will be proportionately more rapid and complete. To 
admit of this concentration of vitality upon a particular part 
of the body, the system elsewhere seems to suffer, as it were, 
a transfer of some portion of the vital energy allotted to it. 
Hence the resort to counter-irritation, or revulsion, in the 
treatment of disease : an exaltation of life is artificially occa- 
sioned in a particular part of the surface, with the view of 
diminishing or annulling the same condition, as the result of 
disease, in another and generally neighbouring organ. By 
properly varying the means resorted to, the kind and degree 
of action thus established may be suited to the different states 
which it is the object of the surgeon to counteract. These 
means are chiefly rubefacients, vesicatories, and such as pro- 
duce suppuration. 



SECTION I. 
OF RUBEFACIENTS. 

These are applications which excite an erythematous 
inflammation of the skin, terminating in complete resolution, 
and followed frequently by desquamation of the cuticle upon 
which they were placed. Their local action is strictly counter- 
irritant, not combined with any depletory influence ; but, in 
addition to this, they produce a considerable degree of general 

excitement. 

(266) 



OF RUBEFACIENTS. 267 

There are many applications which produce this effect: 
water, sand contained in a suitable vessel, and heated to a 
temperature somewhat above that of the surface of the body 
(from 100° to 150°), will excite an erythema of the skin ; 
the same result follows the application to the surface of the 
aromatic oils and powders, of spirits of turpentine, dilute 
aqua ammonise, the " linimentum cantharidis," and many 
other substances. But the means most commonly employed 
as rubefacients are sinapisms, or poultices made of ground 
mustard-seed. In order to prepare the flour for application, it 
should be mixed with water, and spread evenly upon a piece 
of muslin, having the surface which is to be placed next the 
skin covered with a piece of thin gauze or cambric. The 
efficacy and rapidity of action of the sinapism may be in- 
creased, by adding vinegar to the flour, instead of using water, 
and also by incorporating it with a mixture of oil of turpen- 
tine and water. This applies only to the white mustard-seed 
powder. 

The length of time during which a sinapism should be 
allowed to remain in contact with the skin depends, in a mea- 
sure, upon the sensitiveness of the surface, and the patient's 
general sensibility. In the course of a few minutes after the 
application has been made, a sensation of warmth is induced, 
which becomes more and more powerful, so that after the 
lapse of twenty minutes it cannot be tolerated, generally, with 
any degree of comfort. It should now be removed, and re- 
applied at intervals, upon the same part, or upon other regions, 
as may be indicated. If it be suffered to vesicate the skin, a 
very troublesome sore often results, and sometimes gangrene, 
from excessive inflammation. Attention to the duration of 
the application is particularly necessary when the patient is 
unconscious, or only partially sensible, as the pain arising 
from the action of the mustard, in ordinary circumstances, is 
not complained of now, and great inflammation may be caused 
before this effect is suspected. By combining some other 
kind of meal with that of the mustard-seed, a poultice may 
be made, which will excite erythema more slowly, and which 
may be borne upon the skin for a much longer time. 

The ordinary " spice poultice," — made by mixing together 
the powders of several of the aromatics, as cinnamon, cloves, 
red and black pepper, and mustard-seed, together with wheat 



268 OF VESICANTS. 

or flaxseed meal, or bread-crumbs softened in milk or water, 
— is an excellent and mild rubefacient application. From a 
half teaspoonful to a teaspoonful of each of the aromatic 
powders may be combined with a sufficient quantity of one 
of the other substances, to make the poultice large enough for 
the surface to be covered. 

The general stimulant or excitant action of rubefacients 
should be borne in mind when their application is directed, 
as in many cases this influence will be sufficient to counteract 
their revulsive effect. 



SECTION II. 
OF VESICANTS. 

These are characterized by the effusion of serum beneath 
the cuticle, caused by the inflammation arising from their ap- 
plication. Hence, in addition to their derivative effect from 
the diseased organ, and the general excitement which they 
occasion, they act also as depletants : this last peculiarity 
serves to counteract the injurious impression which would 
otherwise be incident oftentimes to their stimulant action. 

Vesication may be produced by a variety of applications. 
If a very rapid effect is desired, probably the best mode is to 
saturate a cloth, folded to the proper size, in boiling water, 
and lay it upon the surface, taking care that the fluid does 
not flow over a larger space than was intended. A piece of 
metal, raised to a high temperature by being plunged in 
boiling water, and then placed in contact with the skin ; — or, 
according to the recommendation of Carlisle, metal heated to 
redness and passed over the surface, a fold of wetted cloth 
intervening ; — or a jet of steam from the nose of some con- 
venient vessel ; — all these are at times resorted to for the 
purpose of raising a blister speedily. But they cause a degree 
of inflammation which often eventuates in gangrene, and are 
always very painful remedial agents. 

There are three remedies of this class which are simple in 
their application and very manageable, and with which, 
probably, the surgeon may accomplish all that he can hope to 



OF VESICANTS. 269 

gain from the use of vesicating applications. These are the 
Spanish fly, Croton oil, and aqua ammoniae. 

1st. The cerate made of Spanish flies, — " ceratum cantha- 
ridis" of the Pharmacopoeia, — is the preparation which is 
most used. It may be spread on coarse brown paper, or on 
soft leather, or, which is much the most convenient and most ele- 
gant substance, upon a piece of adhesive plaster, as it is pre- 
pared on sheets of linen for use. In covering either of these 
substances with the cerate, a margin should be left all around 
free from the salve. If the adhesive plaster is used, it will 
be necessary merely to warm this margin, in order to make 
the vesicating agent adhere to the skin on which it is placed : 
if any other substance is employed on which to spread the 
cerate, strips of adhesive plaster should be used to retain it 
on the surface. 

Before applying the vesicatory, the skin should be shaved, 
if there be much hair upon it, and moistened with vinegar, 
in order to increase the rapidity of action of the flies ; and 
it is also advisable to cover the surface of the cerate with a 
piece of fine tissue-paper moistened with vinegar, as by this 
means none of the blistering matter will adhere to the skin 
after the removal of the cerate. 

The length of time during which the application should be 
continued varies with the part to which it is confined, the age 
of the patient, and the state of the general sensibility of the 
individual : probably from two to twelve hours may be as- 
sumed as the minimum and maximum duration. The scalp 
being much more tardy in responding to the action of the 
vesicant than any other part of the body, the application 
should be retained longer upon it. It is not necessary to the 
formation of the blister that serum should actually be effused 
beneath the cuticle before the vesicating agent can be re- 
moved. If the skin be rendered of a bright red colour by 
the action of the flies, these may be withdrawn, and a piece 
of linen covered with simple cerate, or a poultice, may be , 
laid upon it, and in a short time the cuticle will be raised by 
the serum poured out beneath it : excepting in some few cases, 
where a very powerful impression is demanded, the desired 
results will be obtained from this course as fully as though 
the vesicatory had been retained upon the part for a much 
longer time ; and this will be found to be the surest way of 
23* 



270 OF VESICANTS. 

preventing the occurrence of strangury, one of the most un- 
pleasant incidents to the use of the Spanish fly as a blistering 
application. In children this method should always be pur- 
sued, the cerate being kept upon the skin for two or three 
hours only, and then it will be rare that gangrene, or a very 
high degree of inflammation, will endanger the life which the 
blister has perhaps rescued from the grasp of some formidable 
disease. 

A very elegant and convenient preparation of cantharides 
is the " cantharidal collodion," as it is called; it is made by 
dissolving gun-cotton in an ethereal solution of cantharides. 
It is applied upon the skin by means of a camel's-hair pencil. 
It is prompt in its action, and the intensity of its effects may 
be pretty well regulated by the manner in which it is used. 
To produce a very speedy and comparatively severe vesica- 
tion, a thick coating of the solution should be applied, and 
then covered with oiled-silk. 

The mode of dressing the blistered surface will depend 
upon the effect which is desired. If it be not important to 
encourage a continued secretion or discharge from the skin, 
the cuticle should be simply punctured with a needle, or with 
the point of a thumb-lancet, and the serum be suffered to 
escape, and simple cerate, or a soft poultice, be subsequently 
laid upon the surface ; in a day or two the irritation will have 
subsided. But if a continuation of the secretion be desired, 
the cuticle should be removed, having been first cut around 
its adherent edge, and the exposed surface of the true skin 
dressed with basilicon cerate, or with savine cerate. If, as is 
sometimes the case, the surface be very painful and much in- 
flamed, a soft poultice or cold water will be found the best 
dressing. A sloughy condition of the part will be best com- 
bated by the application of one of the acids sufficiently diluted, 
or creasote, or decoction of oak-bark, or the solution of La- 
barraque, together with the internal administration of suitable 
tonics. When a blistered surface is tardy in healing, Dr. 
Wood strongly recommends the application to it of "the 
cerate of subacetate of lead diluted with an equal weight of 
simple cerate. " 

Blisters should always be dressed with great gentleness, as I 
every one will feel who has had the misfortune to have been 



VESICANTS. ill 

tered. The tearing off the cuticle, recommended by some, 

is n. barbarity. 

If strangury should occur, despite the precautions having 
been taken to prevent it, as above recommended, the patient 
may drink pretty freely of flaxseed tea. or if copious draughts 
of liquids be objectionable from particular circumstances, 
speedy relief will follow an enema of a scruple of camphor 
and twenty or thirty drops of laudanum suspended in an 
ounce or two of water or mucilage. 

The affections strictly surgical, in which blistering by this 
means is most efficacious, are, probably, periostitis — the blister 
being produced directly over the seat of pain ; — fractures re- 
maining long ununited — where the blister is created in order 
to excite the vessels of the bone and surrounding soft parts 
to an increased activity of function, with the hope of repair- 
ing the injury: — erysipelas — in order to produce a more 
healthy kind of inflammation, and thus to arrest the spread 
of the disease; — and gangrene, — the object being the same 
as in the last affection. Besides these, many others may be 
enumerated as being "more or less benefited by the employ- 
ment of vesicating remedies, such as caries, the various oph- 
thalmic diseases, neuralgia, chronic articular inflammations, 
indolent glandular and other swellings. 

The general excitant effect of this class is one of the most 
important therapeutic characteristics, more marked in this 
than in the class last considered. 

'2. Croton oil — the " Oleum Tiglii" of the Pharmacopoeia 
— is a very mild and manageable Gaunter-irritant. It is more 
adapted to chronic than to acute diseases ; its general stimu- 
lating effect is much less than that of cantharides, and its 
depleting action is comparatively slight ; as a local derivative. 
however, it exerts a decided impression, and this may be 
maintained for a long time wi:h less inconvenience to the 
patient than by the employment of the Spanish fly. 

The effect of Croton oil may be obtained either by fric- 
tions, or by the incorporation of the oil with some Bort 
plaster, so that the compound may be spread upon a suitable 
substance, as leather, and worn upon the surface of the body. 
The first is the method usually adopted, as vesication is occa- 
sioned more speedily by this than by the plaster. The oil 
should be diluted with one or two parts of olive oil, or it n 



272 OF VESICANTS. 

be used in its concentrated strength, as the skin upon which 
it is to be rubbed is more or less tender, and as a less or more 
rapid action is desired. It is common to moisten a piece of 
flannel with a few drops of the oil, and to rub it over the 
surface until the skin is decidedly reddened and made to 
smart ; this operation should be repeated after an interval of 
six or eight hours, and a third time, if necessary ; two or 
three applications will generally be sufficient, unless the oil 
has been much diluted. The vesicles are numerous, some- 
times coalescing, sometimes remaining distinct, each one being 
surrounded by a red areola, which, if the vesicles are near 
together, give the skin a uniform erythematous injection. 
The fluid is at first clear, but soon becomes turbid and puru- 
loid. The irritation subsides after a few days, when the ap- 
plication may be renewed, if indicated. 

If the other method of employing the oil be adopted, as 
recommended by Dr. Graves, of Dublin, it may be incor- 
porated with lead-plaster, in the proportion of 3j. of the oil, 
to 3ij. or Kij. of the plaster, and spread upon kid; or Bur- 
gundy-pitch may be substituted for the lead-plaster. This 
application will produce a vesicular eruption after it has been 
worn upon the surface for a day or two. 

In using the Croton oil, it should be recollected that an 
irritation of the skin will be produced wherever the oil shall 
happen to come in contact with it, as on the eyelids and face 
from accidentally touching these parts with the fingers on 
which a little of the oil has remained ; the consequent burn- 
ing sensation and swelling are soon relieved by the applica- 
tion of cold water. 

3. The strong water of ammonia — "Ammoniae liquor 
fortior," — may be used when a very rapidly vesicating agent 
is needed. It is applied by saturating with it a piece of linen 
folded to the proper size, and laying it upon the surface to 
be blistered, where it should be confined for two or three 
minutes, care being had that the liquid does not flow upon the 
surrounding skin. 

The blistering lotion of Granville contains this preparation 
of ammonia as its active agent. He directs two lotions of 
different powers ; these are prepared thus : 

Strongest water of Ammonia | and -| 

Distilled spirit of Rosemary , i " f 

Spirit of Camphor i " i 



SUPPURATIVE COUNTER-IRRITANTS. " 273 

" The stronger lotion has been employed by Dr. Granville 
only in cases of apoplexy and for the purpose of cauteriza- 
tion. The first two ingredients are to be gradually mixed ; 
whereupon the mixture becomes opalescent and gives out an 
ethereal smell. Before the addition of the third ingredient, 
the mixture should be rendered transparent by means of a 
little alcohol. These lotions are stated to produce as full a 
vesication in a space of time varying from three to ten 
minutes, as can be produced by cantharides in as many hours. 
They are applied by means of folds of linen impregnated 
with them." (U. S. Dispensatory, art. " Ammon. Liq. fort.") 

They are used chiefly to relieve violent neuralgic pains. 



SECTION III. 
OF SUPPURATIVE COUNTER-IRRITANTS. 

The remedies of this class act less promptly than rube- 
facients, or vesicants, but when the secretion of pus which is 
excited by them has become established, they produce a more 
depressing effect, inasmuch as the development and conti- 
nuance of a suppurative discharge involve a greater expen- 
diture of vital energy than is called for to produce an ery- 
thema, or a vesication. Any application which will cause a 
loss of substance of the surface on which it is made to act, 
will occasion suppuration from the granulations by which the 
reparation of the tissues is accomplished. Thus the strong 
mineral acids, the actual cautery, even a vesicant if it pro- 
duce a sufficiently high degree of inflammation, will give rise 
to suppuration. The substances most employed with this 
view, however, are, tartar emetic, caustic potassa, nitrate of 
silver, the seton, the issue, and the moxa\ 

1. Tartar emetic is most frequently used in the form of 
the ointment made by incorporating the salt with lard, in 
varying proportions according to the strength required ; one 
part of tartar emetic to two parts of lard makes a powerful 
ointment; a more common proportion is one of the former to 
four, or even eight, of the latter. The strong ointment will 
produce pustulation in the course of a few hours. 

The mode of using this agent is, to rub a portion of the 



274 SUPPURATIVE COUNTER-IRRITANTS. 

preparation upon the skin for some minutes, until pain and 
redness are excited ; if a single application be not sufficient, 
it should be repeated at intervals of a few hours. Suppu- 
ration from the ulcers thus induced should be favoured by 
dressings of some stimulating cerate, or by poultices. 

A saturated solution of tartar emetic in warm water, to be 
rubbed upon the skin by the aid of a piece of flannel, is a very 
neat and cleanly method of producing pustular inflammation. 
Another, and a very convenient mode of using this agent is, 
to sprinkle a little of the powder upon the surface of a Bur- 
gundy pitch, or other adhesive plaster, which is then laid 
upon the skin, and there retained until pustules are deve- 
loped. 

2. Nitrate of silver, commonly called lunar caustic, pro- 
duces an eschar much less deep than tartar emetic, and con- 
sequently is a less powerful application than the other. It is 
used by moistening a stick of the caustic and rubbing it upon 
the skin. As a caustic, it is employed to cause a superficial 
slough which, when it has become detached, leaves a healthy 
granulating surface, as in the treatment of chancre, and old 
ulcers. 

3. Caustic potassa, prepared in the form of "sticks," is a 
much more effectual pustulating application than the last. 
With this, the tissues may be destroyed to almost any extent 
and depth, and great care is therefore necessary in making 
use of it. The best and safest plan is, to lay upon the skin a 
piece of kid, in which a hole is cut corresponding in size and 
situation with the portion of the skin on which the caustic is 
intended to act ; then the potassa, slightly moistened, is to be 
placed, or rubbed, upon the skin thus exposed, until a suffi- 
ciently thick eschar is produced, after which it is advisable to 
pour a little vinegar upon the part, in order to render inactive 
any portion of the caustic which may still adhere to the tis- 
sues. The separation of the slough, thus produced, should be 
hastened by the application of warm poultices, and the granu- 
lating surface, left exposed after the detachment of the eschar, 
should be dressed with slightly stimulating lotions, or cerates, 
to encourage the secretion of pus. 

The "Vienna paste," recommended by surgeons on the 
continent of Europe, is made by triturating together, with the 
aid of a little alcohol, five parts of caustic potassa and six 



SUPPURATIVE COUNTER-IRRITANTS. 275 

parts of quick-lime. The compound is used in the same man- 
ner as the caustic potassa alone, and produces an eschar in a 
few minutes, with less pain than the other. 

A paste, made by incorporating chloride of zinc with wheat 
flour and water, is recommended by many surgeons as a caus- 
tic. ML Canquoin prepares it of different strengths, accord- 
ing to the desired effect ; thus, he triturates one part of chlo- 
ride of zinc with two, three, four, or five parts of flour, adding 
fifteen drops of water for every ounce of the flour. The paste 
thus formed is divided into cakes, varying in thickness from 
one-twelfth to one-third of an inch, and applied to the part ; 
the eschar which it causes may be from one line to an inch 
and a half deep, according to the thickness of the portion of 
caustic, the duration of its application, and the character of 
the tissue to which it is applied. (U. S. Dispens.) 

The white oxide of arsenic is now rarely used as a caustic : 
its application is generally attended with great pain, and un- 
pleasant constitutional effects have often followed it. 

Iron heated to whiteness has been, in earlier times, much 
resorted to as a means of producing a slough and subsequent 
suppuration. It is now, however, seldom employed for this 
purpose. When used thus, the iron is called ;i the actual 
cautery," in contradistinction from the other caustics, to 
which the term, potential cauteries, has been applied. 

4. The moxa, as it is ordinarily used, consists of a cylinder 
of carded cotton, about an inch long and from one to two 
inches in diameter, the whole wrapped in a piece of linen and 
impregnated with a saturated solution of nitrate of potassa, 
or of chromate of potassa. To apply it, one of the extremi- 
ties of the cylinder should be lighted in the flame of a lamp, 
and the other placed upon the skin, the roll being beheld be- 
tween the blades of a pair of dressing-forceps. The moxa is 
maintained in a state of ignition by blowing upon it with the 
mouth, through a blow-pipe, or with the lips merely, the object 
being to secure a steady heat. The pain experienced from 
this application becomes gradually more and more severe, 
until the sensitive structure of the skin is destroyed, when it 
ceases. A thick eschar is thus formed, which, by the con- 
tinued application of emollients, becomes detached after some 
days, leaving a granulating, suppurating surface, requiring 
dressings suitable for such a condition. 



i 



£76 SUPPURATIVE COUNTER-IRRITANTS. 

The moxa is generally employed as a counter-irritant in 
diseases of the bones, as caries of the spine, and is applied 
near to the seat of the affection, — not so near, however, as 
to involve the vessels and nerves in the slough which is 
formed. 

5. Issues are established by the introduction into the sub- 
cutaneous tissue of some foreign body which acts as an irri- 
tant, and thus perpetuates a suppurative secretion. The sub- 
stance generally used for this purpose is made of cork, or pine 
wood, or indeed of any similar material, cut to about the size 
and shape of the common garden-pea. It is introduced into 
the tissue either by an incision made with the knife, or it may 
be confined by means of strips of adhesive plaster upon the 
granulating surface, produced by the action of caustic potassa, 
or a vesicating agent. 

There is some choice as to the point at which the issue 
should be established ; it may be directly over the seat of the 
disease, or, if this be not important, at some remote point. 
The arm and the back of the neck are the most convenient 
situations for the formation of an issue ; in the former, the 
pea should be introduced in the space between the biceps and 
deltoid muscles, near the insertion of the latter. When the 
neck is selected, any point may be taken which seems most 
convenient ; it should generally be low down, so that the pa- 
tient's dress may conceal it from view. 

6. Setons are established by passing a piece of tape, or a 
skein of silk, or other similar material, through a portion of 
the integuments, and leaving it to excite suppuration. The 
seton may be introduced by means of the instrument con- 
trived by Boyer for the purpose, — a blade shaped somewhat 
like that of the thumb-lancet, but stronger and curved also, 
and having an eye cut in its heel, through which the seton- 
tape, or silk, is passed (fig. 126); — or it maybe effected sim- 
ply by using a common bistoury and an eyed-probe. In either 
case, the first step of the operation is the same : a fold of the 
integuments is pinched up between the thumb and fore-finger 
of the left hand, and the blade of the instrument, previously 
oiled, — be it the seton-needle, or the bistoury, — is thrust 
through its base ; if the seton-needle is used, it should be 
armed with the tape, or silk, and drawn through, its armature 
following , if the bistoury is employed, the probe is armed in 



SUPPURATIVE COUNTER-IRRITANTS. 277 
Fig. 126. 




the same way, and passed along the base of the wound upon 
the blade (fig. 127). After the needle or the probe has thus 



Fig. 127. 




cleared the incision, it is disconnected from the seton, and 
the extremities of the latter are tied together, forming a loop 
which encloses a portion of the integuments ; a poultice 
should be laid upon the wound, and retained in place by a 
proper bandage, for a few days, until suppuration has become 
established, when simple cerate may be substituted as a dress- 
ing, and confined by adhesive strips. The seton should be 
drawn daily backwards and forwards across the wound, in 
order to stimulate the latter slightly, and to sustain the dis- 
charge ; and once or twice every week a clean seton should 
be introduced, by attaching one end of it to one of the ex- 
tremities of the tape already in use, and drawing it within the 
wound. 

Any part of the surface of the body may be selected for 
the establishment of a seton, — the blood-vessels and nerves 
being avoided, of course, — but the back of the neck, or the 
24 



278 OF ACUPUNCTURE. 

upper part of the arm, is usually chosen as being the most 
convenient part. 

Dr. Golding Bird has suggested and repeatedly practised 
a mode of inducing a continued purulent discharge from the 
surface, which is free from the objections generally enter- 
tained by patients against the methods in common use. It 
is an elegant adaptation of electricity to medical purposes. 

He advises two small blisters to be applied to the surface 
at the desired part, one a few inches from the other ; when 
the cuticle has become raised by serum, " snip it, and apply 
to the one from whence a permanent discharge is required a 
piece of zinc-foil, and to the other a piece of silver ; connect 
them by a copper-wire, and cover them with a common water- 
dressing and oiled silk. If the zinc plate be raised in a few 
hours, the surface of the skin will look white, as if rubbed 
over with nitrate of silver. In forty-eight hours a decided 
eschar will appear, which (still keeping on the plates,) will 
begin to separate at the edges in four or five days. The 
plates may then be removed, and the surface where the silver 
was applied will be found to be completely healed. A com- 
mon poultice may be placed upon the part to which the zinc 
was applied, and a healthy granulating sore, with well-defined 
edges, freely discharging pus, will be left. ,, 

Dr. Bird's explanation of this interesting phenomenon is, 
that the chloride of sodium contained in the fluid exuded be- 
neath the cuticle is decomposed; — the chlorine being evolved 
at the zinc plate, forms with the metal a chloride of zinc, 
which is an escharotic. 

This means will of course be applicable whenever, for any 
purpose, it is desired to destroy a surface, whether of the skin 
or of an ulcer. (London Medical Gazette, vol. iv., N. S. 
1847, p. 981.) 



ACUPUNCTURE. 

For convenience-sake, the modes of practising acupuncture 
and vaccination will be considered in connexion with this 
chapter, although neither of these operations are performed 
with a view of effecting cutaneous irritation merely. 



OF ACUPUNCTURE. 279 

Acupuncture. — The instrument by which this is accom- 
plished is a needle about two inches long, having a cylindri- 
cal shaft tapering towards one extremity to a sharp point ; 
the other end is received into a small handle of ivory or of 
steel, or it is simply coated with sealing-wax. The needle is 
made sometimes of steel, sometimes of one of the precious 
metals. In introducing it, the instrument is held perpendi- 
cularly upon the surface, and forced through the skin to the 
requisite depth by a rotatory movement, combined with a 
sufficient pressure upon the point. The punctures are made 
in muscular, tendinous, or aponeurotic tissues, whichever may 
be the seat of suffering, and the depth of the puncture must 
of course depend upon the position of the tissue affected. It 
is advisable to allow the needle to remain in the part for a 
length of time, as for a half hour, an hour, or even longer, 
since a more permanently beneficial effect is thus produced 
than when the instrument is withdrawn at once. The needle 
may be extricated by making slight pressure upon the sur- 
face, and withdrawing the instrument with a rotatory move- 
ment. 

No accident follows the operation, generally ; rarely more 
than a drop of blood appears at the puncture ; the chief ves- 
sels and nerves are always avoided, and the puncture should 
not penetrate any of the important cavities, or viscera. 

Electro-puncture consists in passing through needles, intro- 
duced as above described, a current of electricity collected in 
a Leyden jar, or generated in a small voltaic pile, which is 
connected with the needles by ^ metallic wire passing to each 
pole of the battery. 

Both these varieties of acupuncture are frequently of ser- 
vice in the treatment of neuralgia, and of rheumatism un- 
attended with inflammation ; in the treatment of indolent 
tumours also, by promoting their removal by absorption ; 
in the cure of local paralysis, &c, &c. Simple acupuncture 
is very often resorted to in order to evacuate anasarcous col- 
lections. 

Local pain of a violent neuralgic character may be re- 
lieved in many instances, and speedily, by rubbing upon the 
surface thus punctured a solution of sulphate of morphia, con- 
taining several grains in each ounce of water. 



280 OF VACCINATION. 



VACCINATION. 

The operation, as generally practised, consists in inserting 
beneath the cuticle, at some convenient point, the matter of 
the cow-pock. 

Several methods have been adopted for the collection and 
preservation of vaccine matter. If it were practicable, the 
simplest method would be, to transfer the liquid vaccine 
lymph from the arm of one child to that of another — upon 
whom the operation is about to be performed. But since this 
proceeding is not always convenient or possible, the virus 
must be collected and preserved in the liquid state, or in the 
form of the dry crust. In the liquid state, it may be pre- 
served between two small plates of glass. Or capillary tubes, 
having a bulb at one extremity, may be placed in contact, at 
the open end, with the lymph of the fifth or sixth dry vesi- 
cle, — the air in the bulb having been rarefied by the warmth 
of the hand, or of the mouth, is again permitted to cool and 
contract, when the fluid will enter ; so soon as a sufficient 
quantity has collected in the bulb, the extremity of the tube 
should be sealed in the flame of a spirit-lamp and blow-pipe. 
But the most convenient method to be pursued in the pre- 
servation of the virus is, to permit the lymph to dry, either 
on points of ivory, or as a scab upon the surface at the site 
of the vaccination. If the latter be adopted, the crust may 
be very well kept by being enveloped in tin-foil, or between 
two pieces of wax excavated to receive it. The author has 
recently vaccinated several children with a scab which has 
been thus preserved for two years ; the vesicle was developed 
in each case, and passed through its customary phases with 
perfect regularity. 

The operation may be performed with a thumb-lancet, or 
with a lancet made expressly for vaccinating ; this differs 
from the thumb-lancet only in being smaller. The virus may 
be introduced beneath the cuticle, by means of lateral punc- 
tures made with the point of the lancet; or, the skin having 
been rendered tense between the thumb and fore-finger of the 
left hand, placed upon the part of the surface selected for the 
seat of the operation (generally the arm above the elbow), 



OF VACCINATION. 281 

the cuticle may be removed, over a minute space, by slight 
scratches with the point of the lancet, crossing and recrossing 
each other until the vascular surface is reached, (blood being 
just made to appear,) and then the virus be applied thereon. 
If the liquid lymph be used, it is simply requisite to moisten 
the lancet therewith, and to apply the blade upon the exposed 
surface ; if the points of ivory be employed, one of them may 
be inserted beneath the cuticle, according to the first method 
of operating, or placed in contact with the denuded surface, 
if the second plan be adopted ; if the scab be selected, a small 
particle of it should be reduced to powder and moistened with 
a little water, being rubbed to a pulpy consistence by the aid 
of the lancet-blade, which should now be wiped upon the 
abraded skin, so that a sufficient portion of the vaccine mat- 
ter shall come in contact with the absorbing surface. After 
the operation is completed, the part should be left uncovered 
until the surface has become perfectly dry; the subsequent 
stages which the vaccine disease assumes, in the development 
and maturation of the vesicle, should be carefully watched, in 
order that a correct opinion may be had as to the efficacy of 
the operation. 



24 5 



CHAPTER IV. 



ON THE METHODS OF ARRESTING HEMORRHAGE. 

The occurrence of bleeding, as an accident, or in connexion 
■with an operation, always claims the prompt attention of the 
surgeon, and often demands the manifestation of all his skill 
and self-possession. 

In the consideration of this subject we shall describe the 
methods found most efficacious in arresting haemorrhage, and 
state the circumstances to which each is most applicable. 

1. By the action of cold. This is the simplest method of 
arresting the flow of blood from a wound, and its efficacy is 
exemplified daily, the mere evaporation which takes place at 
the surface of the wound reducing the temperature of the part, 
thereby favouring the coagulation of the blood and exercising 
a degree of constriction upon the bleeding vessels. This effect 
may be increased by exposing the divided tissues to a current 
of air, naturally or artificially excited. Bleeding from super- 
ficial wounds, or abrasions, when no vessel of notable size is 
opened, may generally be checked by this simple mode. 

The application of cold water, or of ice, to the bleeding sur- 
face, or to its immediate vicinity, is still more effectual, and 
will very often arrest haemorrhage from small arteries. Dr. 
G. N. Burwell, of Buffalo, informed the author very recently, 
that he had succeded in stopping profuse bleeding from a deep 
transverse wound of the palm of the hand, by the constant ap- 
plication of ice during twenty-four or thirty-six hours. The 
ice may be placed in direct contact with the wound, or it may 
be enclosed in linen, or in a bladder. If cold water is used, 
it may be simply laid upon the surface in saturated lint, or it 
may be employed by douche, or irrigation ; the latter is the 
most efficacious. Evaporating lotions may be found effectual 
sometimes, in the absence of ice. 

2. By the application of astringents, and styptics. These 
act, probably, in a twofold manner, — upon the organic proper- 

(282) 



METHODS OF ARRESTING HEMORRHAGE, 283 

ties of the bleeding vessels and surrounding tissues, and also 
upon the blood itself; causing by the former, a constriction, 
a greater or less degree of closure, of the vessels, — and by the 
latter, favouring coagulation of the effused blood which me- 
chanically prevents the escape of more. There are many sub- 
stances which induce coagulation of blood, not by any chemi- 
cal, or vital, agency which they exert, or develope, but simply 
by opposing the flow at numerous points, so that it becomes 
retarded, and then coagulates by its own inherent properties ; 
such are cob- web, filaments of lint, powdered sugar, and other 
similar domestic remedies. 

The astringent and styptic applications which have been 
found most serviceable for the purpose under consideration 
are, powdered alum ; powdered galls ; sulphate of copper and 
of zinc, also in powder; creasote, and the tincture of the mu- 
riate of iron. Fluids act most rapidly because they come most 
speedily in contact with the points from which the blood es- 
capes ; they are applied usually by means of a brush of camel's 
hair, or upon a feather, passed over the surface ; or by satu- 
rating with them a piece of lint which is pressed lightly upon 
the part. If a powder is used, it may be sprinkled over the 
surface, or retained upon it by gentle pressure. The tincture 
of the muriate of iron is probably the best of these means. 
These agents will generally suffice to arrest bleeding from vas- 
cular surfaces, no large vessel being opened, — for example, in 
haemorrhage from the mucous membrane lining the nostrils, 
in bleeding ulcers on the neck of the uterus, in bleeding he- 
morrhoidal tumours. 

Matico, a plant growing in South America, has been lately 
recommended as possessed of particular efficacy in arresting 
haemorrhage. Dr. Ruschenberger, of the U. S. Navy, has 
employed it in a large number of cases, and bears strong testi- 
mony to its value as a hemostatic agent. He used it success- 
fully to arrest bleeding from a bubo which had been opened 
by the knife, and from which the blood issued in full and free 
jets, long-continued and well-applied pressure having failed to 
arrest it ; it likewise caused the cessation of bleeding from hae- 
morrhoids removed by incision, which had produced trouble- 
some haemorrhage, resisting other applications of various kinds. 
The mode which Dr. Ruschenberger advises for its employ- 
ment is, to break the dried leaves into a coarse powder and to 



284 METHODS OF ARRESTING HEMORRHAGE, 

form -with this, by the aid of water, a pultaceous mass, which 
should then be placed upon the bleeding surface and retained 
there by very light pressure, — a pressure which would not 
prove sufficient, of itself, to arrest the bleeding. Dr. R. speaks 
highly of the efficacy of matico, ta£en in infusion, for sponta- 
neous haemorrhage, having proved its value in profuse monor- 
rhagia, in hsemophthisis, and similar cases. 

3. By cauterization. This produces an eschar, sealing up 
the orifice, or orifices, from which the blood escapes. So long 
as the eschar remains adherent to the vessel, it presents a me- 
chanical impediment to the further escape of blood ; but when, 
in the process of nature, the slough has become detached, the 
haemorrhage will recur, unless the vessel has become perma- 
nently obliterated from its open extremity as high up as the 
first branch above it; hence the patient should be carefully 
watched about the time at which the slough seems inclined to 
separate, lest the bleeding should return unexpectedly. In 
the choice of a cauterizing agent, therefore, some one must be 
selected which shall produce an eschar sufficiently deep to re- 
main adherent, until nature shall have accomplished the per- 
manent closure of the vessel between the points mentioned. 
The fact should be borne in mind that, the application of any 
caustic will prevent the possibility of union of the wound by 
the first intention. The actual, or the potential cautery, may 
be used. 

In employing the actual cautery, the metal, generally iron, 
should be heated to whiteness and then applied upon the sur- 
face for a few seconds only ; both of these precautions are ne- 
cessary, for if the iron be of a lower temperature than that 
which constitutes ' white heat,' the eschar occasioned by it is 
less perfect and its action is more painful ; and if the cautery 
be kept too long in contact with the tissues, it adheres to them, 
and when it is withdrawn, it removes the eschar with it, 
thereby destroying, of itself, the good which it had accom- 
plished. 

The form of the cautery should be adapted to the character 
of the part to which it is to be applied : thus, if the wound be 
narrow, and the bleeding vessel lay at the bottom of it, the 
iron should be sufficiently long and small to reach to the ori- 
fice of the vessel. The annexed drawing illustrates some of 
the most common forms of the actual cautery. (Fig. 128.) 



METHODS OF ARRESTING HAEMORRHAGE. 285 

Fig. 128. 




- 
.;i.SB3h.., ImMv. iftuki ,iL 

The actual cautery is now rarely used to arrest haemorrhage, 
this object being almost always effected by some other means 
more simple, and less shocking in appearance. The cases in 
which it is still recommended are, in operations upon the bones 
of which the medullary membrane is excessively vascular ; in 
the bleeding which sometimes follows the extraction of a tooth, 
and in others similar. 

Of the potential cauteries, those most used are, the nitrate 
of silver, and concentrated sulphuric acid. The former may 
be employed in the solid state, its extremity having be-en 
previously more or less pointed, by friction upon the surface 
of a wet rag, or in concentrated solution, as of 9j to a fluid- 
ounce of water, applied, as is the acid, by means of a brush. 
The efficacy of lunar-caustic, in stick, in arresting bleeding 
from leech-bites, has already been mentioned. The solution 
of the salt, or the sulphuric acid, is often of service in 
haemorrhage from incised or ulcerated surfaces, which are too 
much removed from sight to admit of nice inspection and 
handling, and from those which present no apparent vessel, 
or bleeding point : thus bleeding ulcers or wounds on the neck 
of the uterus are sometimes treated, a speculum vaginas being 
used to assist the surgeon in the application of the remedy. 

4. By directly obliterating the vessel which gives out the 
blood. This may be a temporary or a permanent effect, as 
the means used are temporary or permanent in their action. 
Transient obliteration may be best induced by simple pressure 
upon the vessel ; permanent occlusion is produced by torsion, 
and the use of the ligature. The former is applicable to all 



286 METHODS OF ARRESTING HEMORRHAGE. 

varieties of accidental bleeding, whether it be arterial, venous, 
or capillary ; the ligature and torsion are employed almost 
exclusively in arterial haemorrhage. 

Pressure. — The mode of making the requisite compression 
varies according to circumstances. 

If there be a wound bleeding moderately, or if the blood 
be of a venous character, it very often happens that the 
haemorrhage is arrested by the mere apposition of the edges 
of the wound, if it be an incised wound ; or by the simple 
pressure upon it of the dressings, if it be such as not to admit 
of apposition of its lips. When the divided vessels are of a 
larger calibre and bleed more freely, pressure should be made 
W 7 ith the aid of a compress and adhesive plaster, or a roller 
(as in fig. 125). Direct pressure upon a wound is objection- 
able, particularly if it be a lacerated or contused wound, or 
if much pressure be required to produce the desired effect, 
because it will interfere with the reparation of the injury, and 
may induce sloughing. When positive pressure is to be ex- 
erted for the sake of the compression, the vicinity of the 
wound should therefore be selected as the site of its applica- 
tion, rather than the wound itself. 

Pressure is employed also to prevent haemorrhage during 
operations, as in amputations, and likewise in accidental 
wounds, as a temporary expedient, until some more perma- 
nent measure be adopted. For this purpose, the compressive 
force may be applied at any point at which it can be most 
effectually and conveniently exercised. The simplest method 
of instituting this measure, is to press the fingers upon the 
course of the vessel through which the circulation is to be 
arrested. With this object, some point should be selected 
where the vessel is readily felt pulsating ; and, if possible, 
this point should be favourably situated with regard to some 
bony support, so that the vessel can be pressed against the 
latter, and thus be completely obliterated. For example, the 
facial artery should be compressed against the edge of the 
lower jaw, at the anterior margin of the masseter muscle ; 
the temporal and occipital arteries, at any point of their 
course, at which they can be felt ; the brachial artery, by 
grasping the biceps muscle, at the middle of the arm, between 
the fingers and thumb of the right hand, and at the samo 
time pressing the artery against the bone with the points of 



METHODS OF ARRESTING HEMORRHAGE. 287 

the fingers, on the inner side of the muscle, (fig. 129 :) the 
axillary artery, by thrusting the fingers, — their points approx- 
imated, — into the axilla, and forcing the artery against the 

Fig. 130. 




head of the humerus ; the subclavian artery, by pressing the 
thumb down upon the vessel, behind the clavicle, upon the 
point at which the artery crosses the first rib on the external 
side of its tubercle ; generally, the artery cannot be suffi- 
ciently well compressed by the thumb, and it is necessary, 
therefore, to employ some instrument for the purpose, as a 
common door-key, of which the ring should be wrapped with 
a piece of linen, and then pressed upon the vessel, as above 
advised ; the femoral artery, by placing one thumb upon the 
vessel, at the point where it crosses the ilium to descend the 
thigh, and making the requisite pressure by the other thumb 
acting upon the first, (fig. 130 ;) the abdominal artery, by 
causing the patient to occupy a position whereby his back and 
thighs shall be flexed, and the abdominal parietes relaxed, and 
then pressing the artery against the spinal column. 



288 METHODS OF ARRESTING HEMORRHAGE. 



But, although it is not necessary in most cases, to exert 
much force with the fingers, the muscles are very soon fa- 
tigued, so that the pressure becomes unsteady and uncertain, 
if it be maintained for any length of time ; and moreover, 
the fingers are liable to become displaced by any sudden 
movement of the patient ; hence the necessity of employing 
some compressing force which shall not be liable to these 
objections. The tourniquet offers such advantages. 

The tourniquet, in its most common form, is very well 
represented in the annexed drawing, (fig. 131.) It is so con- 
trived, that when the strap is buckled around the limb, by 

Fig. 131. 




turning the screw the soft parts are compressed and the pad 
forced upon the artery. Before applying the tourniquet, the 
surgeon should examine it carefully, to see that it is in good 
order, — the screw, strap and buckle strong, — so that it shall 
not fail when most needed. A firm pad should be made, of 
a cylindrical shape, for application over the artery, and the 
strap secured around the limb. The screw should not be 
turned too rapidly, and no more compression should be exer- 
cised about the limb than may be necessary to prevent the 



METHODS OF ARRESTING HEMORRHAGE. 289 



flow of blood below the point of pressure. A long-sustained 
application of this instrument is productive of considerable 
pain, and therefore it should be avoided. 

The points upon which the tourniquet is applied to the 
limbs are not fixed. Mr. Fergusson recommends those indi- 
cated in the accompanying drawings (figs. 132, 133, 134), 

Fig. 132. Fig. 133. 




290 METHODS OF ARRESTING HEMORRHAGE. 



preferring compression of the artery in the popliteal region, 
when the leg is to be amputated below the knee, rather than 
of the femoral artery at the upper part of the thigh. 

An ' impromptu' tourniquet, for use in emergencies, con- 
sists of a cravat, in the middle of which a knot is formed ; the 
cravat is made to encircle the limb, the knot corresponding in 
situation with the artery : the two extremities are then tied 
together, a piece of stick inserted between them and made to 
revolve until the limb is sufficiently compressed. This is com- 
monly called the field-tourniquet. (Fig. 135.) 



Fig. 135. 



Fig. 136. 





An objection to the ordinary tourniquet is, that it con- 
stricts the whole limb, preventing the circulation through the 
veins as well as through the arteries, causing considerable 
pain and swelling, if continued beyond a short time. To ob- 
viate this difficulty, compressing instruments of various kinds 
have been invented : they have not, as yet, arrived at such 
perfection as to be, on the whole, preferable to the tourniquet 
in common use. The compressor of Dupuytren " consists of 



METHODS OF ARRESTING HEMORRHAGE. 291 

two steel-plates (fig. 136), half an inch broad, curved and 
joined at the centre of the instrument in such a manner as to 
allow of the curve being increased or diminished at will. To 
these plates two others, which support pads, are attached : 
one of the pads is movable, the other fixed; and in applying 
the instrument, the movable one is placed over the artery, the 
other rests upon the opposite side of the limb. The pressure 
is made by the movable pad, and is regulated by a screw." 
(Liston's and Miitter's Lectures on Surgery, p. 42.) 

Dr. Dorsey (Elements of Surgery, vol. i., p. 57) mentions 
a very simple and ingenious expedient by which the same 
effect was attained. " The patient was a child, in whom 
several unavailing attempts had been made to tie up the 
divided vessel (an artery in the foot), and the wound was in a 
state of great inflammation. A compress was applied over 
the trunk of the anterior tibial, and another over that of the 
posterior tibial artery, about two inches above the ankle; 
over these a strip of sheet copper was passed around the leg, 
and a tourniquet applied over the copper : when the tourni- 
quet was tightened, the tibial arteries were compressed and 
the bleeding ceased, the copper preventing the tourniquet 
from compressing any other vessel, so that the circulation in 
the foot w r as not interrupted. In a few days the wound healed 
without any recurrence of haemorrhage." 

Since the treatment of aneurism by compression has become 
a standard measure, great improvements have been made in 
the construction of tourniquets, and the great desideratum 
seems to have been, to a considerable extent, gained, viz.: to 
exercise a moderate, but sufficient compressive force upon 
the artery, without interfering materially with the return of 
the blood through the veins. The fact has become established, 
that, to cure an aneurism, it is not essential absolutely to pre- 
vent the arterial circulation, but merely to reduce it to a cer- 
tain sluggish current. Several instruments have been con- 
trived which produce this effect ; and they can, moreover, so 
completely obliterate the artery, as to be adapted for use in 
amputations, or in other cases where it is necessary that the 
arterial flow should be stopped, for the time. The Dublin 
Surgeons, particularly Drs. Bellingham, Carte and Tafnell, 
deserve most of the credit for these improvements. 

Fig. 137 represents an instrument of this kind, designed 



292 METHODS OF ARRESTING HEMORRHAGE. 

for application to the middle of the thigh ; and fig. 138, one 
for the groin. 

Fig. 137 




Fig. 138. 




METHODS OF ARRESTING HEMORRHAGE. 293 



If employed simply for the purpose of arresting or prevent- 
ing haemorrhage, only one tourniquet or compressor will be 
required. But if applied for the cure of aneurism, it is con- 
sidered better to use two, so that when the pressure caused by 
one becomes disagreeable, the other can be brought into ser- 
vice immediately. 

Dr. Carte's compressor, as represented in fig. 139. possesses 

Fig. 139. 




this peculiar feature, that, in addition to the common screw 
force, a certain degree of elasticity is gained by the introduc- 
tion of bands of vulcanized India-rubber. 

Plugging- of the divided vessel, or of a wound, is sometimes 
resorted to for arresting the flow of blood when other means 
have failed. It acts by compressing the vessel, or by me- 
chanically stopping its orifice. It is rarely done now, except- 
ing occasionally when blood continues obstinately to flow from 
the cut extremity of the bones in amputation : here a piece 
of lint, or of wood, having a ligature attached to it. is gently 
pressed within the cavity of the bone, or within its reticulated 
structure, and allowed to remain, the ligature hanging from 
between the edges of the flap, so that the plug may be re- 
moved when it has fulfilled its intention. 
25* 



294 METHODS OF ARRESTING HEMORRHAGE. 

Torsion is now but little resorted to. It consists in twist- 
ing the vessel several times upon its axis, so as to rupture its 
inner and middle coats, which then become more or less 
inverted, as when cut by a ligature. Many methods of per- 
forming this simple operation have been advised, of which the 
simplest is probably as effectual as any. The artery should 
be seized at its open extremity by a pair of serrated forceps 
(fig. 140), with which it is drawn out from the wound, and 

Fig. 140. 




isolated from its connexions with the surrounding tissues ; it 
is then held in the grasp of a pair of catch-forceps placed 
across its axis, at the distance of half an inch from its open 
end, and twisted several times in the direction of its axis by 
means of the first forceps (fig. 141) : the torsion having been 

Fig. 341. 




thus accomplished, the vessel is returned into the wound. 
This is not generally trusted to as a safe and certain means 
of arresting haemorrhage, excepting in the instance of small 
arteries. If the vessel can be thus seized and twisted, a liga- 
ture can certainly be applied to it as well, and will scarcely 
give rise to more irritation than the portion of the artery thus 
violently crushed and reduced to the condition of a foreign 
body in the wound. 

The ligature offers the most safe and permanent means 



METHODS OF ARRESTING HEMORRHAGE. 295 

of obliterating an artery of a size sufficient to admit of its 
application. 

The object had in view in the employment of the ligature 
is, the division of the internal and middle coats of the artery ; 
these retract within the canal, giving the latter the appear- 
ance of a cone, of which the apex points towards the ligature. 
The cavity of the vessel, from the ligature to the first branch 
above it, becomes filled with a coagulum of blood, and the 
same coagulating process takes place in the blood which has 
been effused outside of the vessel; soon, however, a perma- 
nent obliteration occurs, from a vital process, some degree of 
inflammation and exudation of plastic matter being occasioned 
by the irritation of the ligature, and a complete consolidation 
of the tube ensuing from union of the internal tunic of the 
artery w T ith the organizable mass within it. 

Many substances have been recommended as materials for 
the ligature. It has been supposed that leaden ligatures 
excite less irritation in the midst of the tissues than those of 
any other material ; ligatures made of animal fibre, as of the 
sinew of the deer, have been supposed to be removed by 
absorption at the point at which they are tied ; but these are 
probably mistaken ideas ; no one now thinks it advisable to 
incur the trouble of preparing ligatures of such materials, for 
the sake of any advantage which fancy may attribute to them 
over the ordinary ligature, made of saddler's silk, or of com- 
mon flaxen thread. 

A single strand of strong saddler's silk, or of good home- 
spun thread, will answer for application to small arteries ; 
but when the vessel is larger, the ligature should be corre- 
spondingly more thick, as of from two to four strands. These 

Pig. 142. 




should be well waxed, and twisted firmly and roundly, in 
order to cut the coats of the artery, as before mentioned, a 
flattened ligature not effecting this object. Hence also in 



296 METHODS OF ARRESTING HEMORRHAGE.' 



Fig. 143. 



applying the ligature, the knot must be drawn tightly. For 
the purpose of seizing the artery, in order to isolate and tie 
it, the forceps figured on p. 295 (see fig. 142), having a toothed 
extremity and a spring-catch to keep this closed, is a very 
convenient instrument, less so, however, than the tenaculum 
(fig. 143) — a hook with a long curve sharp at 
the point — which is inserted into the mouth of 
the vessel, and by which the latter is drawn out. 
The artery being thus brought within reach, it 
should be separated from its connexions with the 
surrounding tissues, vessels, and nerves, for the 
space of a few lines, and the ligature applied 
around it, behind the tenaculum, or forceps. It 
is sometimes proper to include a portion of the 
surrounding tissues in the knot, as when the 
coats of the artery are supposed to be weakened 
from inflammation or other cause, or when the 
mouth of the vessel which bleeds cannot itself 
be seen, and yet the surgeon is assured that it 
is within the mass which he has raised upon his 
tenaculum, or by his forceps. If an artery of 
considerable size has been divided, it is advisable 
to tie both extremities, as otherwise the bleeding 
may be renewed from that portion of the vessel 
which was not at first emitting blood, but into 
which an anastomosing current has afterwards 
discharged itself: this precaution is particularly necessary in 

situations where the anastomosis 
of arteries is known to be com- 
mon, as in the palm of the hand 
and on the foot. 

" The sailor's knot," as it is 
called, is the one best calculated 
to secure the artery firmly ; it 
forms, when tightly drawn, a flat 
knot which will not slip. The 
accompanying drawing illustrates 
it better than a verbal description. (Fig. 144.) 

The vessel having been tied, one division of the ligature 
should be cut off close to the knot, while the other is left 
hanging from the wound. When many vessels have been 



Fig. 144. 




METHODS OF ARRESTING HEMORRHAGE. 297 

tied, the ligatures thus cut should be grouped together and 
allowed to project at one extremity of the wound, of which 
the edges should then be approximated : when one of the 
vessels tied is of large size, as the main artery of a limb, the 
ligature which is attached to it should be indicated by a knot 
made at its free extremity. 

The length of time during which the ligature remains con- 
nected with the artery, varies according to the size of the 
latter ; generally, from five to twenty days may be considered 
as elapsing before the external coat of the vessel becomes 
severed at its point of constriction; then the ligature i3 
loosened and falls from the wound, or may be readily drawn 
from it. After the usual time has passed, the ligature may 
be gently twisted and drawn upon, in order to favour its 
release, as sometimes it is retained by the granulations in 
which it is imbedded, after its attachment to the vessel has 
ceased. The ligature appertaining to the largest vessel 
should be handled more carefully than the others. The 
patient should be carefully watched about the period at which 
the ligatures become detached, particularly when large ves- 
sels have been tied, lest an unexpected haemorrhage occur. 
Secondary bleeding requires the same treatment as the 
primary. 

The forceps and tenaculum are the only instruments re- 
quired for tying a vessel which presents itself at the surface 
of a wound. But it often happens that the bleeding artery 
cannot be seen, it having retreated within the substance of 
the tissues : it then becomes necessary either to slit open the 
tissues from the point at which the haemorrhage appears, or 
to cut down upon the course of the vessel above the wound, 
and pass a ligature around it at this point ; the former is a 
very uncertain and disagreeable operation, the latter is speedy, 
simple, and sure. The incision having been made at the 
point at which the vessel is most accessible, the object is to 
inclose the latter in the loop of a ligature without including 
the accompanying vein or nerve. To enable the surgeon to 
effect this, several instruments have been contrived, to which 
the term aneurism-needles has been applied. The simplest, 
and one which answers very well almost always, is shown in 
the following drawing (fig. 145) ; it needs no farther descrip- 
tion. When the sheath of the vessels has been opened, the 



298 METHODS OF ARRESTING HEMORRHAGE. 

extremity of this needle, armed with a ligature, is carried 
under the artery and brought out on the opposite side, when 
one division of the ligature is seized between the fingers, or 

Fig. 145. 




by a forceps, and drawn out upon one side, while the other 
portion follows the needle as it is removed at the other side 
of the wound: the vessel is then tied, as above advised. 
Professor Gibson has invented an admirable instrument for 
passing a ligature beneath deep-seated arteries. It consists 
of a flattened canula of silver sufficiently strong, curved 
rather more than the common aneurism-needle figured above, 
and fitted to a handle ; through the interior of the needle, of 
which one extremity of the cavity opens near the handle on 
the back of the needle, and the other at the point, a piece of 
watch-spring passes, having an eye at the extremity nearest 
the handle, and terminating at the other end in a head of 
silver ; the ligature is placed in the eye of the spring, and 
the needle is passed beneath the artery; then the spring, 
which is considerably longer than the needle, is pushed 
through the cavity of the instrument and appears upon the 
opposite side of the vessel, carrying the ligature with it. 
Belloc's instrument, illustrated by fig. 148, would answer 
very well in many cases where the artery is deeply located. 
But in the majority of instances, a ligature can be readily 
passed around a vessel by means of the grooved director and 
the eyed-probe, which are in every one's pocket-case. The 
director is introduced beneath the vessel, and carried com- 
pletely across the wound, so as to rest upon the edges of the 
latter, the artery being raised upon it ; then the probe, armed 
with the ligature, is slid along the groove of the director, 
beneath the artery, and drawn out upon the opposite side 
with the ligature. In some instances, the bleeding artery is 



METHODS OF ARRESTING HEMORRHAGE. 299 

concealed behind a 'projecting bone, as, for example, the 
internal pudic behind the rami of the ischium and pubis ; in 
order to secure this vessel, Dr. Physick's forceps, having a 
curved needle inserted between its blades, and furnished with 
a hook to compress its handles, will be found the most conve- 
nient instrument. (Fig. 146.) 

Fig. 146. 




The surgeon is sometimes called upon to arrest haemorrhage 
from one of the natural canals, or cavities, particularly from 
the nostrils and rectum. 

Epistaxis occurring in individuals of a hemorrhagic dia- 
thesis, frequently induces a dangerous degree of prostration. 
If it resists the use of cold water, or ice, applied upon the 
face and forehead, or on the back of the neck, and if astrin- 
gent powders blown into the nostrils, or injections of astrin- 
gent solutions, fail to arrest it, the nostrils must be plugged. 
Stopping the anterior orifices of these cavities will not suffice, 
as the blood will continue to escape through the posterior 
nares ; both must be stopped therefore. To effect this, a 
piece of thin wire may be doubled upon itself, and the folded 
end introduced along the floor of the nostril, from before 
backwards, until it has traversed the passage and appears at 
the back part of the mouth ; the surgeon then seizes this 
looped extremity with his fingers, or forceps, introduced into 
the mouth, draws it forwards, — the body of the wire still 
resting on the floor of the nostril, — and passes a cord through 
it, the centre of the cord corresponding with that of the loop, 
while the ends are loose ; the wire is now drawn out of the 
nose in the direction by which it was introduced, one of the 
divisions of the ligature emerging with it, the other remain- 
ing in the surgeon's hand ; to the middle of this portion of 
the cord a piece of lint is attached, to serve as the plug, 
which is drawn into the posterior nares by the first division 
of the ligature ; the anterior nares are next to be plugged, 
by inserting lint, and the haemorrhage is thus effectually 



300 METHODS OF ARRESTING HEMORRHAGE. 

Fig. 147. * 




arrested. At the end of two or three days, the plugs may 
be removed, the posterior being drawn out by means of the 
extremity of the cord which has been left hanging from the 
mouth. (Fig. 147.) See Liston and Mutter, p. 185. 

A very elegant and useful instrument for plugging the pos- 
terior nares has been invented by M. Belloc. It is a canula 
of silver, A, curved very much like a catheter, but smaller. 
Through this canal a straight stem of silver, B, is introduced, 
to which is attached a piece of watch-spring, C, terminating 
in a rounded head which has a hole drilled in it for the in- 
sertion of a ligature. The free extremity of the straight 
rod, B, has a button attached to it, to prevent it from being 
draw r n out of the canal ; a ring is soldered to the inferior 
surface of the canula, to aid in holding the instrument. (Fig. 
148.) In introducing this, draw the watch-spring entirely 




METHODS OF ARRESTING HEMORRHAGE. 301 

within the tube so that the head shall form a smooth convex 
extremity to the instrument ; then the tube is passed along 
the floor of the nostril, the curve presenting downwards, until 
its head reaches the extremity of the naso-palatine septum, 
when the watch-spring is pushed out, its curved form causing 
it to find its way directly into the mouth ; the head is now 
drawn forwards, and a ligature, with a plug of lint attached, 
is passed through the eye ; the remainder of the operation is 
managed precisely as with the wire above spoken of. 

In hemorrhage from the rectum, if the bleeding vessel 
cannot be tied, or if the blood comes from the venous plexus, 
astringent powders should be introduced ; if these fail, a 
piece of bladder, or a portion of the intestine of some animal, 
filled with pounded ice, should be inserted within the sphincter 
ani as high up as may be necessary. But the presence of 
these foreign matters, as well as of the effused blood, after a 
time excites the expulsive efforts of the muscles and they are 
discharged. In a case of this kind which occurred some 
years ago at the Pennsylvania Hospital, during the attend- 
ance of Dr. Thomas Harris, lately chief of the Naval Bureau 
of Medicine at Washington, all these and other methods of 
arresting the bleeding failed ; it w T as stopped by pressure 
upon the bleeding point, effected by means of a finger intro- 
duced into the rectum and held there for many hours, so long 
as any disposition to recurrence of bleeding was manifested ; 
— so soon as one individual became fatigued he was relieved 
oy another. 



26 



CHAPTER V. 

ON THE DRESSING OF WOUNDS. 

The exposure of the wound for inspection constitutes the 
first step in its treatment. This should be accomplished very 
carefully, after the manner recommended to be pursued with 
regard to the examination of fractures. The arrest of 
haemorrhage should next engage attention ; this will be 
effected by some of the means already adverted to. It should 
be borne in mind that, if it be probable that the wound may 
be made to close by direct union of its edges, this will be 
prevented by the application of styptics or escharotics to 
check the bleeding, and therefore if the simple pressure pro- 
duced by the apposition of the edges of the wound, and the 
means used to secure this, be not sufficient to stop the flow 
of blood, the ligature should be applied to such arteries as 
bleed. In a simple incised wound, all the vessels of sufficient 
size to require a ligature are seen pouring out blood; but in 
wounds accompanied by severe contusions and lacerations, 
such as are caused, by the bursting of fire-arms, or by 
machinery ; it is not at all uncommon to see the arteries of 
the largest calibre projecting an inch or more from the midst 
of the torn muscles, and vibrating with every beat of the 
heart, yet not emitting a drop of blood ; in such cases, liga- 
tures should still be applied to these arteries, and at a point 
w T here their coats seem to be uninjured ; otherwise, after the 
wound has been dressed, and the vitality of the injured 
parts has become restored by warmth and rest, profuse bleed- 
ing will occur and render it necessary to reopen the wound. 
It is neither important nor advisable to tie very small arte- 
ries, as a short exposure to the air and moderate pressure 
will generally prevent these from bleeding, and an unneces- 
sary number of ligatures will interfere very much with the 
healing of the wound. 

All foreign substances, such as dirt, sand and gravel, splin- 

(302) 



DRESSING OP WOUNDS. 303 

ters of wood, fragments of clothes, shot, &c, should be care- 
fully removed from the wound by the aid of forceps, or with 
the fingers, or by allowing a stream of warm water to flow 
gently over it. Coagulated blood should not be permitted to 
remain upon the injured surface, but should be regarded as a 
foreign body, as much as any of the substances enumerated. 
These preliminary measures having been attended to, the pro- 
per mode of dressing the wound must be determined upon ; 
and in the selection of the pieces of the dressing, it should be 
borne in mind that lightness and cleanliness are of great im- 
portance in inducing a rapid cure. 

If the wound must heal by granulations, the surgeon should 
not attempt to confine its edges in apposition, as a consider- 
able degree of compression must be exercised to effect this, 
causing pain without any adequate good. He should be con- 
tented with simply placing the limb, or other part, in the 
most favorable position to ensure ease and rest, and cover the 
wound with a suitable dressing, — cold water or a poultice, 
generally, at first, to allay pain and to combat inflammation, 
followed, when these symptoms have subsided, by the appli- 
cation of an appropriate cerate, or lotion ; these dressings 
should be retained upon the surface by strips of adhesive 
plaster, or by a light bandage. In severe contused and lace- 
rated wounds, the best primary application is cold water, in 
the form of irrigation. (See Part I.) 

When the wound is of such a character as to afford fair 
reason to expect reparation by the first intention, its surfaces 
should be placed in apposition along their whole extent, from 
the bottom to the top, and not along its edges merely ; other- 
wise, though the latter may adhere to each other, granulations 
will form beneath the external lips, or summit of the wound, 
and a collection of matter be the result, which will eventually 
burst through the adhesion formed above it, and then the sur- 
face will necessarily be disfigured by a cicatrix which might 
have been avoided. The proper apposition of the walls of the 
wound may be secured by the use of adhesive plaster, by su- 
ture, and by suitable bandages, — by one or all of these means. 
Before resorting to any of these, however, the part, particu- 
larly if the wound be deep, should be placed in such a posi- 
tion as shall most relax the muscles involved : thus, for exam- 
pie, if there be an incised wound cutting across the muscles 



304 DRESSING OF WOUNDS. 

on the front of the thigh, the limb should be raised upon an 
inclined plane, and the back elevated in like manner; with- 
out this simple precaution, the sides of the wound can be 
but imperfectly retained in apposition by any compressive 
means. 

1. The mode of applying strips of the common adhesive 
plaster, and of isinglass plaster, has been already described 
(see Part I.) : aided by a proper position of the injured part, 
the strips will be found adequate to secure the adhesion of 
most wounds. When the extent of surface upon which the 
strips can be applied is not sufficiently great to ensure firm 
support, their power may be much increased by placing a 
narrow strip of plaster near to, and parallel with, each edge 
of the wound, and crossing the main strips upon them. 
Again, if the strips are subjected to much strain, it will be 
found of importance to make moderate pressure upon the 
muscles by means of a roller, or bandage of Scultetus. In 
removing this dressing, the precautions advised in the first 
part of this volume should be attended to. 

From his own experience, the author ventures to think that 
the reports with regard to the irritation caused by the ordi- 
nary adhesive plaster of good quality, and the liability of 
erysipelas being occasioned by it, are very much exaggerated. 

Recently it has been ascertained that "collodion" a solu- 
tion in ether of the " gun-cotton," as commonly prepared, is 
possessed of very strong adhesive properties; it may be spread 
upon linen or silk, and then applied to the surface ; and it 
offers this advantage over other adhesive matter, viz.: that, 
being insoluble in water, the parts surrounding the wound 
may be washed without disturbing the wound itself, by re- 
moving the plaster which covers it. To separate the plaster 
from the surface, it is necessary to moisten the application 
with ether. (See p. 38.) 

Gun-cotton is made by saturating carded cotton in a mix- 
ture of equal parts of strong nitric and sulphuric acids, then 
washing the cotton in water, and drying it at a temperature 
of 150°, or less. 

2. Several kinds of suture have been invented for the pur- 
pose of securing perfect apposition of the surfaces of incised 
wounds. They are passed directly through the skin at the 
edges of the wound, or through strips of adhesive plaster pre- 



DRESSING OF WOUNDS. 305 

viously applied near to its margins : to the former, the term 
"wet suture" has been given, the latter is called "the dry 
suture.'' Of the first there are four varieties in common use: 
the interrupted, the continued, the quilled, and the twisted 
suture. 

The interrupted suture is made, by passing a needle armed 
with a single strand of saddlers' silk, or of some other equally 
strong material, through the skin from without inwards, en- 
tering at the distance of two or three lines from the edge of 
wound, crossing the latter, and re-entering the skin at the 
opposite margin of the wound, to re-appear a few lines from 
the edge : the two portions of the thread are then tied toge- 
ther in the sailors' knot, as shown in fig. 144. The number 
of sutures thus made varies with the length of the wound and 
the strain which must fall upon each knot ; generally, their 
number should not be greater than may be necessary to re- 
tain the lips of the wound in close apposition. In order to 
diminish the number of sutures, by supporting each one, strips 
of adhesive plaster may be laid across the wound, between 
each two sutures, leaving space enough between the latter 
and the edges of the plaster, to allow of the escape of fluids 
from beneath. Additional aid is sometimes given to the 
stitch by a roller, or a bandage of Scultetus, passed around 
the wounded part ; but this should be avoided whenever it is 
practicable to do so, as the dressing is thereby rendered less 
light and cool. 

In most cases, the surfaces of the wound will have become 
sufficiently adherent, after the lapse of forty-eight hours, to 
admit of the withdrawal of the sutures ; this may be effected 
by passing the sharp point of a pair of narrow T -bladed scissors 
beneath the thread and cutting it, after which it may be 
gently drawn out. If allowed to remain longer than two or 
three days in the skin, the suture excites inflammation and 
slight ulceration around itself, thereby deforming the appear- 
ance of the cicatrix. The strips of adhesive plaster and, if 
necessary, the bandage also, should be retained, in order to 
give security to the recently formed adhesions, after the re- 
moval of the suture. The following drawing illustrates 
the application of the interrupted suture. (Fig. 149.) 

The continued suture is less used than the last. It is the 
one employed in wounds of the intestines, and also in closing 
26* 



306 



DRESSING OF WOUNDS. 



Fig. 149. 



the incisions made in conducting post-mortem examinations. 

It is the stitch commonly used in 
sewing, and is otherwise called 
the glover s stitch. The needle 
is first entered as in making the 
interrupted suture ; it then crosses 
the wound obliquely from the op- 
posite side to the margin first 
penetrated, and is again inserted 
at a point below the first, thus 
crossing and recrossing the wound 
obliquely until a sufficient num- 
ber of stitches have been laid, 
when the ends of the thread are 
1 1 % secured, at each extremity of the 

wound, by being tied around the 
first and last stitch respectively. The distance between the 
stitches must depend upon the length of the wound and the 
resistance which they are expected to overcome ; they may 
be aided in their retentive action by the application of a roller, 
or a bandage of Scultetus. 

The quilled suture is now but little used : Mr. Liston says 
of it, " it is only employed in one operation — that for lace- 
rated perineum. I have used it two or three times in cases 
of this kind." It is effected by entering the needle, armed as 
before, at about four lines from the edge of the wound, and 
carrying it downwards to reappear at the bottom of the 
wound ; then ascending just exterior to the opposite lip, it 
emerges at about four lines from the edge, opposite the point 
at which it first entered ; if the wound be very deep, it will 
be more convenient to carry the needle from above downwards, 
on both sides, rather than from the bottom of the wound to- 
wards the surface. A portion of the thread should be left 
extending from each side of the incision, and when a sufficient 
number of stitches have been introduced to support the wound, 
a piece of a gum-elastic bougie, or a quill, of the same length 
as the latter, is placed parallel with the incision on each side, 
between each two strands, which are then tied upon the tube I 
with force sufficient to retain the entire surfaces of the w 7 ound I 
in apposition, after they have been approximated by the hands. 
(Fig. 150.) 



DRESSING OP WOUNDS. 



30T 




The advantages of FlG - 15 °- 

this suture are, that 
it forces the sides of 
the wound together 
throughout its entire 
depth, instead of the 
edges merely, and 
that, by the interven- 
tion of the quills, or pieces of bougie, there is less danger of 
the skin being torn by the threads at the points of puncture. 
A bandage may be employed as an additional support. 

The needle used in these varieties of suture is commonly 
called the surgeon s needle: it is more or less curved, accord 
ing to the fancy of the operator, and has a double cutting 
edge extending about half of its length from the point, which 
should be very sharp ; the 

eve should be lar^e. The Fig. m. 

accompanying drawing re- 
presents two forms of the 
surgeon's needle, of which 
the straigtatest will gene- 
rally be found to be the 
most convenient (fig. 151): 
the size should correspond 
with the thickness of the 

thread to be used, and the part or character of the wound, 
For which it is to be employed. 

The twisted suture is chiefly used to promote adhesion be- 
tween the edges of incised wounds upon the face, especially 
after the operation for the relief of hare-lip. A well-silvered 
pin, very sharp at the point, is passed, with a rotatory motion, 
through the skin, at a point two or three lines distant from 
the edge of the incision, and brought out on the opposite side, 
at the same distance, the extremities of the pin extending be- 
yond the incision ; then the centre of a single strand of 
thread or silk, is thrown over one end of the pin, and crossing 
the wound — of which the lips are now in contact, — is turned 
around the other extremity of the pin, in the form of the 
figure 8 ; thus the threads cross and recross until several turns 
are made. Generally, two pins are introduced, sometimes 




308 



DRESSING OF WOUNDS. 



§§S5pF<£^ 




Fig. 152. more, and thread twisted upon each, as 

above. (Fig. 152.) When the suture is 
thus made, the extremities of the pins are 
cut off by means of a pair of small cutting- 
pliers. The pins themselves should be 
carefully drawn out at the expiration of two, 
or at most, three days, otherwise ulceration 
will be excited around them, and an un- 
pleasant scar will be the result ; the threads should not be 
disturbed for some days longer. When used in an operation 
upon the upper lip, the invaginated bandage, shown in fig. 25, 
will be found a convenient support, if any should be needed. 

Mr. Fergusson is in the 
habit of employing the 
instrument represented in 
fig. 153, for this purpose. 
It consists of a semi- 
circular spring, padded at 
both extremities, which 
passes around the base 
of the cranium, so that 
the pads cause the mar- 
gins of the wound to ap- 
proximate, and thus re- 
move any strain from the 
sutures. The instrument 
is held in position by 
straps. 

A particular kind of 
needle or pin, made of 
silver, with a steel point 
which may be detached, 
has been contrived for 
this suture, but the common pin of good quality answers just 
as well, and is much more convenient. 

The dry suture, as before hinted, is made by surrounding 
the part — a limb generally — with a strip of adhesive plaster 
placed close to each margin of the wound, and passing from 
one to the other as many stitches of the interrupted suture as 
may be required to retain the edges in apposition. 

M. Baudens, chief surgeon to the " Val de Grace" hospital, 




^fc*c 



DRESSING OF WOUNDS. 309 

recommends the following kind of dry suture, to approximate 
the edges of the flap after amputation ; he surrounds the limb, 
above its cut extremity, with a circular bandage, through 
which he passes pins in front and behind, leaving the extremi- 
ties of the pins projecting ; then, while the flaps are brought 
together accurately by an assistant, the surgeon passes from 
one pin to the opposite, pieces of thread, wrapping them 
around the pins with sufficient tightness to retain the flaps in 
apposition. 

M. Vidal (de Cassis) has invented an ingenious little con- 
trivance for retaining the margins of incised wounds in appo- 
sition. He calls it the "Serve-fine" and the Institute of 
France awarded him a prize for it. It is made of fine silver- 
wire, twisted so as to bear a remote resemblance, in shape and 
size, to the "eye' which ladies use in hooking their dresses; 
the end of each leg is bent at a right-angle, and is toothed, 
so as to be capable of piercing and remaining fixed in the 
skin ; and the spring is so arranged that when the " serre- 
fine" is left to itself, after having been properly set in the 
margins of the incision, it approximates these. 

M. Vidal has described and represented this little invention 
in the last edition of his " Traite de Pathologie Externe" 

We think it rather ingenious and pretty, than useful. 

The bandages used to promote union of incised wounds are 
the common roller, the bandage of Scultetus, and the invagi- 
nated bandage. The first two are employed to give support 
merely to adhesive strips and sutures. The invaginated 
bandage acts directly by approximating the edges of the in- 
cision ; its composition and mode of application vary, as the 
wound is longitudinal or transverse. These bandages are 
applied to the extremities generally. 

The invagijiated bandage for longitudinal wounds is thus 
prepared : A linen roller is taken, of a width corresponding 
with the length of the wound, and sufficiently long to make 
several turns around the limb : at the free extremity of this 
roller several slits are made, each about an inch broad and 
six or eight inches long ; and beyond these, at the distance 
of a few inches, fenestrae are cut, in number corresponding 
with the slits, (fig. 154.) Thus prepared, the centre of the 
undivided portion of the bandage is placed directly opposite 
the wound, by the margins of which graduated compresses 



810 



DRESSING OF WOUNDS. 



(a, tf ? fig. 155) have been arranged, one on each side : the 
slits, b, ?>, 5, are passed through the corresponding fenestra, 
e, £, e, and these two portions of the roller drawn in opposite 
directions until the edges of the wound are in apposition; 
(fig. 155.) Then the slits are laid flatly upon the surface. 



Fig. 154. 



Fig. 155. 




and the bandage is completed by circular turns of the roller. 
The efficacy of this uniting bandage is much increased by the 
employment of the compresses, which act very much as the 
quilled suture, by pressing together the entire depth of the 
sides of the wound. It will be found an advantageous mode 
of approximating the surfaces of deep incisions of the thighs, 
particularly. 

The invaginated bandage for transverse zvounds. 

Composition. — A piece of linen from two to three feet 
long, corresponding in breadth with the length of the wound, 
and divided at one extremity into two or more slits, each 
about an inch wide and six inches or more in length, to cor- 
respond with the same number of fenestra made in a second 
piece of linen of the same dimensions as the first ; two rollers, 
each six yards long and two and a half inches wide ; together 
with two graduated compresses. 

Application. — The limb having been placed in a position 
most favourable for relaxing the divided muscles, the surgeon 
makes a few turns of one roller, &, around the limb below the 
wound, and upon these lays the fenestrated bandage, so that 
the divided portion stretches upon and across the incision, 
while the other part rests upon the limb below the wound. 



DRESSING OF WOUNDS, 



ill 



Fig. 156. 



The extremity of this portion is reflected upwards over the 
turns of the roller, which is now resumed and made to secure 
the bandage in position. 
The other band is now 
confined upon the limb 
above the wound, in the 
same manner, by means 
of the second roller," 
the slits corresponding 
in position with the 
wound : next the com- 
presses, c, <?, are placed 
parallel with the edges 
of the incision, one above, and the other below : then the slits 
of one band are passed through the fenestrse of the other, 
(fig. 156.) The two bands are drawn in opposite directions, 
so as to approximate the lips of the wound, and are firmly 
fixed by turns of the rollers passing respectively above and 
below the seat of the injury. 




CHAPTER VI. 



OF THE INTRODUCTION OF THE CATHETER. 



Fig. 157. 



A catheter, in its most general signification, is an open 
tube, made usually of silver, or of gum-elastic prepared in 
a peculiar manner, to which such a form and firmness are 

given as permit of its intro- 
duction into the various canals 
of the body. The passages 
into which such an instrument 
is usually inserted are the 
lachrymal tube, the eustachian 
tube, the oesophagus, the 
urethra, and the large intestine. 
1. Catheterism, or rather 
dilatation, of the lachrymal 
passages, is sometimes prac- 
tised for the purpose of re- 
moving obstructions to the 
escape of the tears along their 
proper excretory passages. 
Before resorting to this opera- 
tion, however, it is important 
to determine if the difficulty may not be an Epiphora, an ex- 
cessive secretion, rather than a Stillicidium. 

It is also essential to bear in mind the natural direction of 
the lachrymal passages, as represented in fig. 157, for it is 
along these same tortuous channels that the dilating instru- 
ment must pass. 

If the puncta lachrymalia be occluded, their minute ori- 
fices may first be opened by the point of a pin, and then one 
of Anel's gold probes (fig. 158) may be introduced, or one of 
the less expensive instruments of which we shall presently 
speak; the size of the dilator should be gradually increased, 
until a permanent cure of the stricture has been gained. 

(312) 




INTRODUCTION OF THE CATHETER. 



313 



It may be that the lachrymal canals, leading from the 
puncta to the sac, are narrowed, in 
Fig. 158. ^nich case the same instrument should FlG - 159 - 
be passed along these passages. To 
dilate the superior canal, the probe must 
be passed almost perpendicularly up- 
wards, inclining a little outwards, then 
obliquely inwards and downwards. In 
operating on the lower canal, pass the 
probe downwards, then obliquely inwards 
and upwards. 

The Nasal duct, running from the 
lachrymal sac to the inferior meatus of 
the nostril, opening below the inferior 
turbinated bone, may be diminished in 
its calibre, and thereby occasion stillici- 
dium lachrymarum. To overcome this 
obstruction, various methods have been 
adopted ; the most feasible is probably that by dila- 
tation. A series of silver probes should be prepared, 
four or five inches Ions:, varving in size from that of 
the No. 17 wire to No. 21, slightly bent, as the one 
illustrated in fig. 159, or straight, if preferred ; one 
extremity may be turned as in the figure, the other 
should be slightly pointed, but not sharp, to enter the 
puncture. In treating stricture of the nasal duct, it 
is most convenient to pass the probe through the in- 
ferior canal, in the manner already explained ; and 
when it has reached the sac, the instrument should 
be pointed almost vertically downwards until it has 
gained the inferior meatus of the nose, which may be 
ascertained readily by passing a probe into the ante- 
rior naris of the side operated upon, and touching the one 
which has been inserted from above. A small sized instru- 
ment should be first used, and after having been introduced, 
should be allowed to remain a few hours, unless much pain be 
occasioned thereby ; and at intervals of four or five days, the 
same or a larger probe should be passed, the size being gra- 
dually increased until the stricture is cured. After each in- 
troduction, it is well to apply warm water with laudanum, to 
allay anv irritation which may have been caused. It is im- 
27 



314 



INTRODUCTION OF THE CATHETER, 



portant to avoid any haste, both in the passage of the prolbe 
at each sitting, and in increasing the size of the instrument, 
in order to guard against the production of inflammation. 

Mr. Morgan has recommended dilatation of the nasal duct 
from below, by introducing a probe, such as is represented in 
fig. 160, beneath the inferior turbinated bone into the lower 
orifice of the duct. This method is less generally practised 
than the other, though highly spoken of by Mr. Morgan. 
(Lectures on the Diseases of the Eye.) 

Fig. 160. 




Anel advised the syringing of the duct with astringent 
solutions. To accomplish this, a fine tube must first be passed 
into the duct from the punctum lachrymale, and the nozzle of 
the small syringe of Anel be fitted into its upper orifice ; 
when the piston of the syringe is being depressed, the other 
punctum must be closed by pressure of the finger, otherwise, 
the fluid will pass out of it from the lachrymal sac. Not 
much can be effected in this way, however, the tube 
being too fine to permit any force of injection. Syringing 
of the duct in this manner, after the use of the probe, may 
assist the operation of the latter, and is useful also in freeing 
the passage from mucus. 

It should be borne in mind, that very much can be done 
for the cure of stillicidium, by correcting any temporary con- 
gestion or inflammation; frequently, indeed, this affection 
may be cured without resorting to such mechanical means as 
we have described. 

For farther details concerning these operations, and espe- 
cially for proper views concerning the pathology of stillici- 
dium, we refer our readers to Treatises on Diseases of the 
Eye, among the best of which is the American Edition of 
Mr. Lawrence's book, by Dr. Hays. 



INTRODUCTION OF THE CATHETER. 



315 



2. CaTHETERISM OF THE EUSTACHIAN TUBE. 

The catheter used in this operation is gene- 
rally of silver, about six inches long, slightly 
curved at the end which enters the tube, and 
gradually increasing in size from this to the 
other extremity. It is open at both ends, and 
it is of very great importance, that the ex- 
tremity which is intended to be passed into the 
canal, shall be well rounded ; otherwise, con- 
siderable irritation, and even excoriation of the 
lining membrane of the tube, will be produced. 
The catheter which Mr. Wilde, of Dublin, one 
of the most dexterous operators and one of the 
best authorities, prefers, is represented in fig. 
161 ; it is here shown in its actual dimensions. 
The ring at the larger extremity of the catheter 
should be in the same plane as the beak of the 
instrument, in order that while the latter is 
being introduced, the operator, by looking at 
the ring, may know the direction of the beak. 

It will be recollected that the pharyngeal 
orifice of the eustachian tube is, according to 
Malgaigne, situated at the distance of two 
inches and a few lines from the anterior orifice 
of the nostril of the same side, on a line with 
the external wall of the meatus inferior, and 
about half way between the floor of the nostril 
and the inferior spongy bone. 

To reach this point with the catheter, the 
following plan, recommended by M. Gairal, is 
probably the best : — The patient being seated 
on a chair, with his head thrown a little back- 
wards and supported upon a pillow, the sur- 
geon stands in front of him and glides the point 
of the catheter, the instrument having been 
oiled, along the floor of the nostril of the same 
side, towards the soft palate : the convexity of 
the instrument should be directed inwards and 
upwards, its concavity downwards and out- 
wards. When the point has reached the velum 
Ipalati, which will be indicated by a movement 
of deglutition, the shaft of the catheter should 



Fig. 161. 





316 INTRODUCTION OF THE CATHETER. 

be rotated through a quarter of a circle, so as to turn the 
point outwards and upwards to the same extent, and at the 
same time pushed backwards for a few lines, when it will 
have entered the expanded orifice of the tube. (Malgaigne's 
Operative Surgery, Brittan's translation, p. 314, 315 — 
London, 1846.) 

Some surgeons prefer a catheter made of gum-elastic, with 
a stilet, so that, w r hen the point of the catheter has reached 
the orifice of the tube, the stilet may be glided into the latter, 
and the catheter itself slid in upon it. But this we cannot 
but regard as an improper instrument; for the operator is much 
more liable to injure the delicate lining membrane of the canal 
with the stilet; and the withdrawal of the latter, as Mr. 
Wilde remarks, is very apt to cause the catheter itself, if it 
have entered the canal, to be disadjusted. 

Generally, the simple opening of the tube by the entrance 
of the instrument, is sufficient to remove any temporary ob- 
struction which may have impeded the free access of air to 
the tympanum. It is sometimes necessary, however, to resort 
to injections of air through the catheter: this should be done 
very gently and cautiously. To accomplish this object, it is 
necessary to have a properly contrived air-press, from which 
the air may be injected, and it is also essential that the catheter 
shall be firmly secured to the head, lest it slip and thereby 
mischief be done. The air introduced may be the ordinary 
atmosphere, or it may be some medicated vapour, according 
to the supposed condition of the lining membrane of the tube. 
Eustachian catheterism, certainly, when associated with this 
farther process, does not properly come under the domain of 
Minor Surgery. It is a delicate operation, and should not be 
carelessly or ignorantly undertaken. Before attempting it, 
more minute instruction should be sought than we pretend to 
give. We, therefore, refer our readers to the special treatises 
on aural diseases, the best of which, we think, is Mr. Wilde's. 
3. Catheterism of the (esophagus. — The object of this 
operation is, to insert a tube into the stomach, for the pur- 
pose of removing fluids from this organ, or of introducing 
them into it. The catheter used is of gum-elastic, of a 
diameter varying to suit the capacity of different gullets, from 
two feet to two and a half feet long, and furnished with a 
flexible stilet made of a thin strip of whalebone ; the extrem- 



INTRODUCTION OF THE CATHETER. 317 

ity which enters the stomach is closed and rounded, but fluids 
reach the interior of the tube, and escape from it, through 
two large eyes, placed one on each side, near this end ; the 
other extremity is open and is usually somewhat expanded, to 
allow of the easy insertion of a syringe-pipe. 

The following is the simplest and readiest mode of intro- 
ducing the instrument : let the patient be seated, if possible, 
his head thrown back and supported, and his mouth widely 
opened, and kept open, if necessary, by a piece of wood, or 
something similar ; then the surgeon, taking his position in 
front of the patient, guides the stomach-end of the tube, pre- 
viously oiled and having the stilet in its cavity, towards the 
posterior wall of the pharynx ; the stilet should now be with- 
drawn, in order to allow the tube to curve more readily as the 
surgeon pushes it downwards through the pharynx and oeso- 
phagus. If the patient be possessed of his faculties, and his 
brain be in a condition to respond to impressions made upon 
sentient surfaces, the tube will be drawn downwards to the 
oesophagus by the contraction of the pharyngeal muscles, as 
in swallowing, so soon as the point of the instrument comes 
within the sphere of their action ; the surgeon therefore is as- 
sisted in the performance of the operation, which is thus made 
much easier. But it happens very often that the patient upon 
whom the operation is being performed has stupified himself, 
so that no reflex muscular action takes place. The entrance 
of the tube into the larynx will be recognised by a spasmodic 
cough, or by the rushing of the air through the canal thus in- 
troduced ; the mistake should at once be rectified. 

Fluids may be thrown into the stomach through the tube, 
by means of a common syringe, or of the stomach-pump pre- 
pared expressly for this purpose. The first is the most sim- 
ple and is equally effectual. Care should be exercised that 
the liquid injected be of a proper temperature. 

If the object be to remove liquid matters from the stomach, 
a certain amount of fluid should be first introduced, either 
simple tepid water, or some other fluid capable of neutralizing 
the noxious matter which may have been swallowed ; then the 
whole should be withdrawn by means of the syringe, and the 
stomach thoroughly cleansed by repeated injections of warm 
water, or mucilage. 

Patients who are unable to swallow, or who obstinately re- 
27* 



318 INTRODUCTION OF THE CATHETER. 

fuse to swallow, food, may be sustained by injections of nutri- 
tious fluids into the stomach through the stomach-tube. 

When it is desirable that the tube shall be allowed to re- 
main in the stomach for any length of time, it is recommended 
to be introduced by the nostril. For this purpose, a tube ra- 
ther smaller is preferable than if the other method be selected ; 
it is pushed backwards along the floor of the nostril, and when 
it has reached the edge of the velum, the stilet is withdrawn, 
and the flexion of the extremity of the tube aided, if neces- 
sary, by the finger carried through the mouth. This method 
is not quite so easy as the first. 

4. Catheterism of the urethra. — Very often the uri- 
nary-bladder, both of the male and female, becomes distended, 
being deprived, from a variety of causes, of its natural expul- 
sive power over its contents; in such circumstances, it becomes 
necessary to resort to some artificial means of relief. In 
many cases, the difficulty may be overcome by employing re- 
medies which tend to relax spasmodic muscular action, such as 
a full dose of opium administered by the mouth, or in the form 
of a small enema ; — or an enema of camphor ; or, again, a hot 
bath may be tried ; often, too, the operation of a full purgative 
clyster will be attended wdth evacuation of the bladder. But 
where these and similar means fail, it is requisite to introduce 
the catheter through the urethra into the bladder itself. 

Catheterism of the urethra of the male. — The in- 
strument used for this operation is a cylindrical tube made of 
silver, or of gum elastic ; it should be about nine inches long 
and of a diameter suited to that of the urethra, which of course 
varies in size according to the age of the individual and to 
certain morbid conditions of the canal ; the extremity which 
enters the bladder should be conical in shape, closed at its 
point, but perforated just above the latter with two or more 
well-opened eyes ; a moderate degree of curvature should also 
be given to this part of the catheter, though a perfectly straight 
instrument may be passed through a healthy urethra; the 
other extremity of the tube is open, and generally has a small 
ring attached to each side of it, for the purpose of affording 
means of confining the instrument in the bladder, if occasion 
require, (fig. 162.) The double catheter represented in fig. 
3, will be found a very convenient instrument. When the 



INTRODUCTION OF THE CATHETER. 319 

Fig. 162. 




gum elastic catheter is used, the proper curve and firmness 
are given to it, by bending the iron wire inserted in its cavity. 

The following will be found the most convenient method of 
introducing the catheter, in most cases : The patient should 
lie upon his back, or be a little inclined towards the right side, 
his thighs semi-flexed and separated, and his back slightly 
raised in order to relax the muscles which would, otherwise, 
somewhat constrict the canal ; the surgeon places himself on 
the left side of the patient, and exposes the head of the penis 
with the thumb and fore and middle fingers of the left hand, 
at the same time making slight compression upon the glans 
penis so as to open the extremity of the urethra : he holds the 
open end of the catheter, previously warmed and oiled, in his 
right hand, between the thumb and the fore and middle fin- 
gers, the concavity of the instrument looking downwards, and 
engages its point in the orifice of the canal, the direction of 
the tube corresponding with the line of flexure of the groin ; 
(fig. 163.) With a moderate degree of force, the instrument, 
still in this line of direction, is pressed onwards through the 
canal until its point reaches the membranous portion of the 
urethra beneath the arch of the pubis, when the right hand of 
the surgeon, and with it the catheter, is gradually raised and 
at the same time carried towards the middle line of the abdo- 
men, after which it should be thrown downwards more and 
more between the thighs ; its passage through the circle of the 
sphincter muscle at the neck of the bladder will be indicated, 
generally, by a slight shiver, or tremor, or a sensation of nau- 
sea, on the part of the patient, and its entrance into the blad- 
der itself by the escape of urine through it ; this should be 
prevented by the application of the thumb upon the open end 
of the catheter. 

With practice, the instrument may be introduced into the 
bladder, if the urethra be in a healthy condition, without 



320 INTRODUCTION OV THE CATHETER. 

Fig. 163. 




touching the penis at all with the hand, after the point of 
the catheter has entered the orifice of the canal ; and this 
will be found to be the least painful method to the patient, 
as well as the one perhaps least liable to obstacles, for the 
instrument will glide along through the urethra without 
being deviated by any forced position of the penis. In 
either method, an instrument of as large a diameter as the 
urethra will admit will be more easily introduced than a 
small one. 

Some of the French surgeons are fond of practising the 
"tour de maitre," as it is called, and this will sometimes 
answer when the more common method has failed. The 
patient may either stand, or lie down, or occupy a sitting 
posture ; the surgeon stations himself on the right side, and 
carries the instrument down the urethra to the arch of the 
pubis, w 7 ith the concavity looking downwards ; when it 
has reached this point, he gives it a turn of a half circle, so 
as to bring it parallel with the middle line of the body, the 



INTRODUCTION OF THE CATHETER. 321 

concavity looking upwards ; this movement, conjoined with 
a little pressure, generally causes the instrument to enter the 
bladder. 

Even in perfectly healthy urethras, the catheter often 
meets with impediments to its course along the canal, but 
these are readily obviated. Thus the point of the instru- 
ment may come in contact with the front of the pubis, 
owing generally to slight deviation of the position of the 
penis, or to too great pressure against the superior surface 
of the urethra from the point of the catheter. Again, when 
the tube has come within the action of the muscles which 
compress the membranous portion of the canal, and, still 
more, when it has reached the neck of the bladder, its farther 
advance will be often checked by the contraction of the mus- 
cular fibres at these points ; but a little patience on the part 
of the surgeon is all that is required to overcome this momen- 
tary obstacle. 

When the cause of the obstruction is an organic alteration 
of the urethra, or of the parts connected with it, much more 
difficulty is experienced in the introduction of the catheter. 
The most common sources of embarrassment of this kind are 
stricture and enlargement of the prostate gland. 

If there be a stricture of the urethra, the size of the ca- 
theter must be adapted to the diminished calibre of the canal ; 
it is necessary, therefore, to have a number of catheters of 
different sizes always at one's command. The resort to much 
force in introducing the instrument should be avoided, parti- 
cularly when the stricture is within the pubic portion of the 
canal, as a false passage may be made more easily at this 
portion than in advance of it. The operation maybe assisted 
by drawing the urethra over the catheter ; by first using a 
large instrument, until the stricture is reached, and then 
drawing the penis over it, so as to make an entrance fully 
into the strictured part, then taking a smaller instrument 
with a resort to the same manipulation. The use of the 
warm-bath, the application of warm fomentations to the peri- 
naeum, or the administration of anodyne enemata, or inducing 
anaesthesia by inhalations of ether or chloroform, will usually 
assist the operation, by relaxing the muscles which directly 
or indirectly constrict the urethra. In the London Lancet, 
for 1851, Mr. Thomas Wakley describes a method of effecting 



322 



INTRODUCTION OF THE CATHETER. 



prompt dilatation of the urethra which may prove very ser- 
viceable in affording relief to persons suffering from retention 
of urine, with stricture. He employs a series of instruments. 
He first introduces a very fine bougie, and upon this, as on a 
director, a small catheter, and so on, gradually increasing the 
size of the catheter, until one of sufficient dimensions has been 
passed. 

M. Amussat frequently resorts to forced injections of the 
urethra, to relieve retention caused by stricture. He intro- 
duces a catheter of gum-elastic, open at both ends, as far 
as the stricture, and then, by means of a syringe, forces a 
stream of warm water along the urethra ; this removes any 
mucus which may have collected, and dilates the canal some- 
what, so that the patient can generally pass a small quantity 
of urine. 

One of the most common causes of difficulty in the intro- 
duction of the catheter, particularly in old men, is an abnor- 
mal development of the prostate gland. The middle lobe 
becomes enlarged, sometimes to a very great degree, and 
encroaches, proportionally to its size, upon the canal at the 
neck of the bladder, thereby opposing a mechanical obstacle 
to the ingress of the instrument. (Fig. 164.) There are 

Fig. 164. 




several expedients by which this difficulty may generally be 
remedied. If the gland be not very large, a silver catheter 
may usually be passed, by pressing the external end of the 
instrument well downwards, when the point -has reached the 



INTRODUCTION OF THE CATHETER. 323 

prostate ; or a gum-elastic catheter may be introduced by 
withdrawing the stilet a little, when the prostatic part of the 
urethra has been attained, and pushing the tube onwards with 
moderate force and cautiously ; the point of the instrument, 
meeting with the obstacle, will yield to it in virtue of the 
flexibility of the gum, and will be thrown upwards so as to 
clear the obstruction. If these methods fail, the surgeon 
should insert the forefinger of his left hand, previously oiled, 
into the rectum, and press the point of the catheter upwards 
towards the pubis : if the gland is very large, the patient 
should assume the erect position, or he may bend his body 
forwards, supporting his hands against the back of a chair or 
a table, so that the mere weight of the prostate will open the 
neck of the bladder to the passage of the instrument. In 
cases of obstruction from this cause, the curve of the catheter 
should be somewhat increased, especially near its point, so 
that it will pass over, and in advance of, the enlarged gland, 
instead of impinging directly against it, as would probably be 
the case were the degree of curvature smaller. 

Many persons suffer very much from the performance of 
this operation, even where there is no stricture ; others, again, 
experience severe rigors, or fainting-fits. If these peculiari- 
ties be known to exist, it is better, unless contra-indicated, to 
put the patient under the influence of ether, or to diminish 
their sensibility by opium ; and if such effects follow the ope- 
ration, morphia should be given to allay them. And in all 
difficult or protracted cases, the same expedients may be re- 
sorted to with great advantage. 

Where much difficulty is experienced in introducing the 
catheter, or in the process of dilating a stricture, it is often 
advisable to allow the instrument to remain in the bladder. A 
silver catheter is borne with rather less comfort than a gum- 
elastic, but the latter soon becomes corroded and roughened 
by the action of the urine upon it ; hence if the gum catheter 
is used, it should be removed at least once in every twenty- 
four hours, and a new one substituted for it. 

A very simple mode of securing the catheter in the blad- 
der is the following : pass a ring made of ivory or of metal, 
covered with linen, or of a cylinder of linen stuffed with 
cotton, over the penis, and secure it against the pubis by 
means of four tapes passing around the pelvis and between 



324 



INTRODUCTION OF THE CATHETER. 



Fig. 165. 




the thighs, on each side ; attach the catheter to this ring by 
tapes connected with the rings of the 
instrument, or tied around its extremity, 
if it be a gum-elastic tube. 

M. Velpeau advises that a piece of 
linen be passed around the penis, just 
behind the corona glandis, and that four 
tapes, secured to the rings of the instru- 
ment, or tied around the extremity, be 
twined about it. (Fig. 165.) The first 
plan will be less likely to cause injury 
to the penis, in case of erection of the 
organ. 

Catheterism of the female urethra is 
attended with fewer difficulties than that 
of the male, owing chiefly to the differ- 
ence in the conformation of the two canals. 

The instrument employed in the operation is made of silver, 
generally ; its form and dimensions may be very well seen by 
a reference to fig. 3, A and B, and to the text explanatory 
of it. But a gum-elastic catheter, even without a stilet, may 
easily be introduced. The only difficulty in the performance 
of the operation, in most instances, consists in inserting the 
point of the catheter into the orifice of the urethra, without 
exposing the parts ; but a very little practice upon the subject 
will enable the surgeon to acquire sufficient skill to operate 
satisfactorily on the living female. 

The simplest rule which can be given for ascertaining the 
position of the orifice of the urethra in the female is this : 
(the patient being on her back,) introduce the tip of the fore- 
finger of the right hand within the labia and the orifice of the 
vagina, and press its palmar surface against the summit of the 
arch of the pubis, at the same time pushing the point of the 
finger a little forwards ; it will now readily and immediately 
feel itself entering the mouth of the canal, which is forced a 
little open to admit its tip. 

The catheter may be thus introduced : place the point of 
the forefinger of the right hand at the orifice of the urethra, 
as just directed, and with the left hand enter the catheter, 
using the finger of the right hand as a guide ; or only one 
hand need be employed, thus : lay the catheter upon the palm 



INTRODUCTION OF THE CATHETER. 325 

of the right hand, the point of the instrument resting on the 
top of the forefinger, the other extremity on the ball of the- 
thumb, and supported in this position by the thumb and 
middle-finger, both somewhat flexed ; now place the tip of the 
forefinger at the orifice of the urethra, in the manner already 
directed, and with the thumb and middle-finger cause the 
catheter to glide along upon the fore-finger and enter the 
canal. 

When the uterus is higher up in the pelvis than usual, from 
any cause, the orifice of the urethra is usually drawn behind 
the arch of the pubis ; in such cases, the point of the finger 
must be introduced a little farther than is otherwise neces- 
sary, in ascertaining the position of the meatus, and rather 
behind the pubis ; but the operation is scarcely rendered more 
difficult on this account. 

It sometimes happens that the urethra is much compressed 
against the pubis by a tumour in the pelvis, as a child's head 
during labour ; in such circumstances, if it is necessary to 
remove the urine from the bladder, a gum-elastic catheter of 
small size should be used, or, which is perhaps better, a flat- 
tened silver catheter ; such an instrument can be had at the 
shops of surgical instrument makers. 

Should it be deemed advisable to allow the catheter to re- 
main for any length of time in the bladder, it may be easily 
secured by applying a double-T bandage around the pelvis, 
and attaching the rings of the instrument to the strips which 
pass between the thighs and over 'the perinaeum. 

5. Catheterism of the large intestine is sometimes 
resorted to, for the purpose of removing the gases which accu- 
mulate so largely in some diseases. Thus, in peritonitis, the 
bowels often become so much distended with flatus, as to 
aggravate the patient's suffering in a high degree. In such 
cases, relief is occasionally obtained from the introduction of 
the common stomach-tube. The mode of performing the 
operation is simple in the extreme ; and yet, from the tortuous 
course of the intestinal canal, it is often exceedingly difficult 
to pass the tube to any considerable distance above the rec- 
tum. The most successful plan is to select a large-sized 
stomach-tube, having within it a stilet of whalebone sufficiently 
thick to impart to the tube a certain degree of firmness, yet 
so flexible as to accommodate itself to the winding course of 
28 



326 INTRODUCTION OF THE CATHETER. 

the canal ; the tube should be oiled, and introduced with a 
rotatory motion and slowly : the point of the catheter may 
often be felt passing along the sigmoid flexure of the colon, 
by the hand placed on the parietes of the abdomen. If the 
operator fail in his first attempt, he should change the posi- 
tion of the patient, and make another effort. It is sometimes 
useful, when the farther advance of the tube seems to be pre- 
vented, to throw a stream of tepid water through it from a 
syringe inserted into its trumpet-shaped orifice. 

6. Catheterism of the larynx and trachea is rarely 
practised ; but in some cases of oedema of the glottis and 
similar obstructions, it may perhaps be advisable to pass a 
tube into the air-passages from the mouth. The operation is 
more difficult of execution than catheterism of the oesophagus; 
sometimes, indeed, it is impossible, as w r hen the rima glottidis 
is spasmodically closed : the patient being seated, or recum- 
bent, the head should be thrown back, the mouth widely 
opened, and the base of the tongue depressed by means of a 
spoon ; then the surgeon, taking a silver tube curved like the 
ordinary catheter for the urethra, but rather larger and open 
at both ends, or a stomach-tube curved by means of a stilet, 
passes it through the mouth directly into the larynx, the pa- 
tient being directed to prolong his inspiratory act : a momen- 
tary cough may be excited by the entrance of the tube into 
the larynx, but this may soon subside, so that the instrument 
may be permitted to remain, having been secured by attach- 
ing its external end to some conveniently-placed bandage, as 
around the neck, for example. 



CHAPTER VII. 

ON THE ADMINISTRATION OF INJECTIONS. 

The term injections, or enemata, is applied to liquids in- 
troduced into the canals or cavities of the body by means of 
syringes contrived for the purpose. 

The matter of the injection consists of water, holding in 
solution, or suspension, certain medicinal substances, intended 
to produce some special effect, — or of water alone. 

The syringes used in the administration of enemata vary in 
form and size, according to the amount of fluid to be injected, 
and the canal into which it is to be introduced. The rectum, 
the vagina, the urethra, and the lachrymal duct are the pas- 
sages which are most frequently acted upon in this manner. 

1. Injections by the rectum. 

The syringes for the rectum are made of different sizes, to 
contain from two fluid ounces to a pint, or more. In select- 
ing them, those instruments should be chosen of which the 
beaks are large and well-rounded at the extremity, so that 
there shall be less probability of inflicting any injury upon 
the mucous membrane of the rectum during their intro- 
duction. 

Before using the syringe, the beak should be warmed and 
anointed with oil, or lard ; and when it is being introduced 
into the rectum, great gentleness and caution should be 
observed, otherwise, as has happened at times, the intestine 
may be torn, or even perforated, particularly when its coats 
are not in a perfectly healthy condition. Its entrance into 
the anus may be facilitated by first passing in the forefinger 
of the left hand, well oiled, and then sliding in the beak upon 
it. While the piston is being forced down with the right 
hand, the head of the syringe should be firmly held by the 
fingers of the left, so that the instrument shall not be pushed 
further into the bowel. The fluid should be forced from the 
tube gradually ; and after all has been ejected, the beak of 

(327) 



i 



828 ADMINISTRATION OF INJECTIONS, 

the instrument should be retained a few moments in the 
rectum, lest, during its removal, the injection pass out with it. 

The above remarks are of general applicability : there are 
some modifications of the process, however, which should be 
borne in mind. Thus, it is frequently advisable that a large 
quantity of fluid shall be thrown into the bowel, a larger quan- 
tity than can be contained in the syringe usually employed. 
In such cases, the instrument must be carefully and slowly 
withdrawn from the anus, refilled, and again introduced and 
emptied, until the requisite amount shall have been injected ; 
or, the self-injecting syringe may be more conveniently used 
— an instrument made like the common forcing pump, having 
connected with it one tube, through which the fluid enters the 
syringe from the vessel which contains it, and a second, which 
is inserted into the rectum, and through which the injection 
finds its way into the bowel. With this very convenient ap- 
paratus, any quantity of fluid may be thrown into'the large 
intestine, until it is filled, either by the patient's self or by an 
attendant. Again, it sometimes happens that an obstruction 
of the lower part of the bowel prevents the introduction of the 
matter of the injection beyond a certain point, if the ordinary 
method be adopted. In such cases, it is customary to pass a 
stomach tube, in the manner recommended in the last chap- 
ter, as far into the canal as may be practicable, and to inject 
the fluid through it. This method will be found effectual, 
oftentimes, in overcoming the constipation which attends some 
cases of colic. 

The composition of the enema must be adapted to answer 
the particular indication for which it is given. When it is 
employed merely to distend the bowel by its quantity, simple 
warm water, or warm mucilage, may be used. The ordinary 
purgative injection consists of a tablespbonful of common salt 
and the same; bulk of molasses, dissolved in a pint of warm 
water, to which a small piece of soap may be added with ad- 
vantage. The anodyne enema consists merely of half an ounce 
or an ounce of mucilage, holding in suspension or solution the 
anodyne element, — as, for example, thirty-five or forty drops 
of laudanum. This small quantity of fluid is preferred, as 
being less likely to induce contraction of the expulsive mus- 
cles by its mere presence, than if a^larger amount were intro- 
duced; and this fact should be recollected in giving any injec- 



ADMINISTRATION OF INJECTIONS. 329 

tion which is intended to be retained in the rectum, to pro- 
duce some general impression upon the economy. 

"Suppositories" are sometimes used as substitutes for ene~ 
mata : they may be so formed as either to induce an evacua- 
tion of the lower bowel, from the irritation of their presence 
in the rectum, — or, in consequence of the absorption of the 
medicated materials of which they are composed, they may be 
retained for a considerable length of time in the gut, and pro- 
duce the peculiar effect of the medicine upon the system. 

The suppository intended to produce catharsis is ordinarily 
made of a piece of castile soap cut to correspond with the 
form and size of the rectum; it should be oiled, and then in- 
serted gently w r ithin the sphincter muscle. 

Any medicine may be administered in the form of a sup- 
pository, by combining it, in the state of powder, with liquo- 
rice, cocoa-butter, or some other soft adhesive substance ; then, 
having reduced the mass to the proper dimensions and figure, 
let it be oiled and introduced into the low T er extremity of the 
rectum. As a general rule, the quantity of the medicine used 
in the suppository may be three or four times greater than 
the proportion of the same medicine, when given by the 
mouth. 

It should be borne in mind that a very frequent resort to 
the employment of suppositories, or to the administration of 
injections, produces irritation of the mucous membrane lining 
the lower part of the rectum, and is apparently an exciting 
cause of the development of haemorrhoids and other organic 
alterations of this portion of the intestinal canal. 
2. Injections by the vagina. 

The vaginal syringe is usually about four inches long and 
an inch in diameter, terminating in a rounded head w r hich is 
pierced with a number of holes, like a sieve. 

No especial directions are required to enable one to intro- 
duce this instrument, farther than that it should be oiled be- 
fore so doing. 

The cavity of the uterus itself may be washed, by passing 
a gum-elastic catheter through the os uteri, and injecting the 
interior of the organ w T ith tepid water or mucilage, by means 
of an ordinary syringe, of which the beak is inserted into the 
open extremity of the catheter. 
8. Injections by the urethra. 
28* 



330 ADMINISTRATION OF INJECTIONS. 

A small glass syringe capable of containing about half an 
ounce, and having a beak well rounded at the tip, is the best 
instrument for injecting the urethra. The piston should ter- 
minate, at its free extremity, in a ring large enough to receive 
the thumb, so that the fluid may be forced from the syringe 
and the syringe itself held by the right hand, while the left 
supports the penis. The beak of the instrument should be 
oiled and inserted very carefully into the orifice of the ure- 
thra, lest the lining membrane be injured. 

It is generally recommended that pressure be made upon 
the perinseum opposite the neck of the bladder, in order to 
prevent the fluid of the injection from entering the cavity of 
this organ; but this precaution is scarcely necessary, if the 
piston of the syringe is forced down with a proper degree only 
of rapidity, and if only sufficient fluid be expelled to fill the 
canal, — the sphincter muscle preventing the fluid from reach- 
ing the bladder itself. 

The interior of the bladder may be acted upon by fluid in- 
jected through the urethra, a catheter having been first intro- 
duced, and the beak of an ordinary syringe, or a gum-elastic 
bag, then inserted into the mouth of the tube. But it is much 
more convenient to use a catheter having two passages, as in 
fig. 166. In the drawing the division of the tube is indicated 
by the dotted line and the star; at a the nozzle of the syringe 
(a) is received; the fluid from the latter passes along to the 
bladder through the eye marked by one of the arrows, and is 
returned from the bladder through that marked by the other, 
to escape from the catheter by d. The stilet c is for the pur- 
pose of removing any obstruction which may occur in the ca- 
theter; it is made of steel, so thin and flexible as to be capable 
of being readily pushed into the chambers of the instrument, 
as indicated by the dotted curved line. (See Mr. Fergusson's 
book, p. 588.) 

Care should be taken, that the fluid thus introduced into 
the bladder has been freed from all solid matter which, if re- 
tained, would serve as the nucleus for calculous formations; 
it should, moreover, be tepid in temperature, and of a slightly 
mucilaginous character. 

In injecting the urethra of the female, a catheter should 
first be inserted within the orifice of the canal, the beak of the 



ADMINISTRATION OF INJECTIONS. 331 

Fig. 166. 




syringe adapted to it, and then the fluid forced through the 
tube into the urethra. 

4. Injection by the lachrymal duct. 

The instrument by means of which this is accomplished, is 
known by the name of " Anel's syringe ;" it is a small syringe 
having a number of very fine tubes appertaining to it, one of 
which, when the duct is to be injected, is attached to the beak 
of the syringe and then inserted into the inferior puncture 
lachrymal. The method of using the instrument is thus de- 
scribed by Malgaigne : " Seat the patient opposite the light. 
If you operate on the left eye, stand before him, and with 
the thumb or fingers of your left hand draw the lower lid out- 
wards and a little downwards, so as to direct the lachrymal 
puncture forwards and outwards. Then, having filled the 
syringe and applied one of the small tubes to the beak, hold 
the instrument as a pen in your right hand, which you rest 
on the cheek, and carefully insert the end of the tube in the 
puncture ; first, obliquely downwards and inwards, then, after 
having entered one line, directly inwards. At the distance 
of three and a half lines you may stop, but it is advisable to 
penetrate as far as four and a half lines, in order to reach the 



332 ADMINISTRATION OF INJECTIONS. 

sac; then inject slowly, at first." On the right eye the ope- 
ration may be performed also with the right hand, by stand- 
ing behind the patient, and resting the hand upon the exter- 
nal orbital process of the frontal bone. If the duct is pervi- 
ous, the fluid thus injected will pass through it and appear 
externally by the nostril ; and if it be not pervious at first, 
the obstruction may oftentimes be removed by repeated use 
of the syringe. The first injection should consist of tepid 
water or mucilage ; subsequently, the fluid may be rendered 
somewhat astringent, or be otherwise medicated. If the in- 
jection cannot be passed through the duct, a fine silver probe, 
of which the point is round and smooth, may be introduced 
as directed for the syringe. 



CHAPTER VIII. 

ON THE REMOVAL OF FOREIGN BODIES FROM THE NATURAL 
CANALS AND PASSAGES. 

1. The globe of the eye, from its exposed position, is very 
liable to have foreign bodies, as particles of dust, cinders, and 
minute insects, come in contact with it ; not unfrequently, 
also, sharp splinters of iron or steel are driven forcibly against 
it and imbed themselves. The pain in such instances is con- 
siderable, sometimes excruciating ; more or less profuse 
lachrymation takes place, and the patient is unable for a time 
to make use of the eye without discomfort. 

Frequently, the profuse secretion and escape of tears are 
sufficient to wash away the offending substance, aided by the 
friction which the patient almost unwillingly exercises. When 
not thus removed, the lids should be well opened and the globe 
carefully examined, while the patient rolls the eye-ball in 
various directions ; if the object be thus brought into view, it 
may be removed by the point of a camel's-hair pencil, by the 
corner of a pocket handkerchief, the end of a tooth-pick or 
probe ; or it may be necessary to throw a fine stream of tepid 
water gently between the lids ; or, finally, if a particle of 
metal or such body be adherent to the structure, it must be 
removed by a pair of delicate forceps, or by the point of a 
cataract needle ; in such cases a magnet would hardly accom- 
plish the removal. 

Very generally the offending object will not be detected by 
the examination to which we have alluded ; it will then be 
necessary to scrutinize the inner surface of the eye-lids. 
The lining membrane of the lower lid may be readily seen by 
depressing the lid, at the same time that the patient rolls the 
eye upwards ; to expose the conjunctiva of the upper lid, the 
surgeon should seize the lashes, and by these draw the lid a 
little off from the globe, place a probe, a tooth-pick, or some 
similar instrument, across the lid just above the superior 
border of the cartilage and parallel thereto, and, while the 
patient looks downwards as much as possible, throw the lid 

(333) 



334 REMOVAL OF FOREIGN BODIES 

over the probe, thus turning it " inside out;" all these steps 
are done at once. If the object be seen, it may be removed 
by any of the means above indicated. 

It must be recollected that the sense of itching, pain, &c, 
occasioned by the pressure of the irritating substance, usually 
remains some time after the cause has been removed. This 
disturbance, however, will commonly be relieved by the ap- 
plication upon the closed lids of tepid or cold water, as is 
most agreeable to the patient. 

2. Removal of foreign substances from the Nostril. 
— Children are not inapt to thrust beans, coffee grains, but- 
tons, and such small bodies, into their own or others' nostrils, 
in fun or malice ; or they may be drawn up into the nose by 
smelling them strongly. Careless or ignorant manipulation, 
instead of dislodging them, only forces them farther towards 
the summit of the nasal chamber. The lining membrane of 
the nose becomes swollen, in consequence of the pressure of 
the irritant and of the efforts made to remove it, blood flows 
more or less freely from the ruptured vessels, and the cavities 
become additionally occluded by clots of blood. When the 
surgeon is sent for he finds the inside, and perhaps also the 
exterior, of the organ swollen, and is unable to see the offending 
substance. In such a case, it is best to syringe the nose with 
tepid water, to dislodge coagula of blood, and inspissated mucus 
which obscure the cavity ; perhaps the same means will likewise 
loosen and wash down the foreign body ; if not, let the sur- 
geon pass a flattened probe, slightly curved, into the nose 
beyond the object, and endeavour to drag it downwards ; the 
spoon-shaped extremity of the silver director will answer this 
purpose very well; or the substance may sometimes be caught 
in the noose of a wire-armed canula. Either of these instru- 
ments will be more likely to succeed in engaging the object 
sought than the forceps, for the latter cannot usually be 
worked with advantage, and even if the foreign substance be 
grasped, it will slip from the blades repeatedly. 

If it be not thrust high up in the nose, and only loosely 
fixed, it may be dislodged by exciting violent sneezing, the 
other nostril being closed the while. 

Occasionally, children are so much frightened by the acci- 
dent and the efforts made to relieve them, as to be entirely 
unmanageable, and thereby expose themselves to injury from 



FROM THE NATURAL CANALS. 



335 



Fig. 167 



attempts at extraction of the foreign body. It is better, 
under these circumstances, to quiet the patient by inhalations 
of ether, and then resume the operation under more favour- 
able auspices, or to wait until the dread shall have passed off. 
There is usually, however, no such difficulty. 

Soothing applications should be made after the operation, 
if the local symptoms seem to require any interference. 

3. Extraction of foreign bodies from the external 
meatus of the Ear. — The lining membrane of the external 
auditory passage, especially near the mem- 
brana tympani, is so exquisitely sensitive, 
that great pain and irritation, sometimes 
convulsions, are produced by the entrance 
of foreign substances. Insects, the most 
common of which is the "ear-wig," splin- 
ters, small pebbles, &c, &c, are not un- 
frequently introduced, or insinuate them- 
selves into the external ear. Attempts to 
remove them should be made with great 
delicacy, as very unpleasant consequences 
have often followed carelessness and rude- 
ness. 

The passage should be examined by the 
aid of the speculum, such as is represented in 
fig. 167, a conical silver tube carefully smoothed, and brightly 
polished on the inner surface, or the little gorget-like instru- 
ment shown in fig. 168 ; and if the object be seen, it may, 

Fig. 168. 





perhaps, be removed by a flattened silver probe, slightly 
curved, or the scoop-shaped end of a director, or the little 
curvette, or the delicate forceps, used by Mr. Wilde. (Fig. 
169.) In consequence of the straightness of the passage, 
however, the surgeon may not be able to manipulate conve- 
niently with, or guide, any of the instruments to which we 



336 REMOVAL OF FOREIGN BODIES 

Fig. 169. 




have alluded, his hand being in the way of his vision ; he will 
then find the forceps illustrated in fig. 170, more manageable. 



Fig. 170. 




But in most cases, more can be done, perhaps, by means of a 
syringe and tepid water, than by any other instrument, and 
W T ith less danger of injuring the patient ; this is particularly 
true if an insect have found its way into the meatus, or if 
wax have became impacted therein. 

It is necessary to guard against inflammation, both before 
and after the removal of foreign bodies from this situation. 
(See Wilde's Aural Surgery.) 

4. Foreign bodies occasionally become lodged in the 
Pharynx and (Esophagus. Small objects, such as pins, but- 
tons, fish bones, are apt to become arrested in the folds and 
pouches at the base of the tongue and palate, causing con- 
siderable uneasiness and constant coughing and hawking, 
rather than actual strangling ; while bodies of larger size are 
caught at the narrowest part of the pharynx, and by their 
pressure upon the larynx, or the spasmodic irritation which 
they produce in it, endanger suffocation. 

The exact point of lodgement should first be ascertained, 
by careful exploration with the fore-finger of the right hand, 
as well as by the eye, of the surgeon — the patient's mouth 



FROM THE NATURAL CANALS. 



337 



being widely opened. The situation having been determined, 
the surgeon may best remove the offending object by his finger- 
nail, or by a pair of dressing-forceps, if it be not too low 
down. 

If the substance in question be impacted in the oesophagus, 
its situation must be ascertained by sounding with the pro- 
bang, (fig. 171,) a flexible rod of smooth whalebone, tipped 

Fig. 171. 




with a sponge, or rounded block of ivory ; if it be low down, 
near the stomach, probably the best course to pursue is to 
push it still onward into this cavity, by means of the pro- 
bang ; if it be nearer to the pharynx and accessible to instru- 
ments, the effort should be made to seize it with the gullet- 
forceps, as represented in fig. 172 ; or, instead of the forceps. 

Fig. 172. 




29 



i 



338 REMOVAL OF FOREIGN BODIES 

a hook attached to a whalebone, as is exhibited in fig. 173, 



Fig. 173. 




Fig. 174. 



may be passed between the body and the wall of the oesopha- 
gus, and then, when it is beyond the former, drawn up again ; 
the instrument being provided with a hinge, which 
permits its blades to close as it is pressed between 
the gullet and the foreign body, while they open 
again when the pressure is removed, and thus en- 
tangle the latter. 

But a much more simple and effectual hook is 
that contrived by Dr. Bond, of this city (fig. 174) ; 
it is so simple that many may be inclined to think 
little of it. It is longer than the common gullet- 
hook, and sets out rather more from the stem at its 
extremity, while at its commencement it forms quite 
an acute angle with the shaft, and is thus capable 
of engaging objects so small as a pin or a needle. It 
is made upon a piece of copper wire, silvered, or 
upon a piece of silver wire, long enough to reach 
even to the stomach, and sufficiently flexible to be moulded to 
any shape. It will be found to be a most efficient instru- 
ment ; indeed, one can accomplish more with it than with any 
other means. 

It is very well to have two pair of gullet-forceps, opening 
in opposite directions, as those figured by Professor Miller, 
(fig. 175) ; in these, it will be observed, the inner face of each 
blade is flat, and toothed near the extremity. Dr. Bond has 
also contrived a gullet-forceps, (see fig. 176), the inner face 
of whose blades are levelled off towards each other, and 
toothed ; and they are so set that they do not come together 
closely ; consequently, there is but little probability of catch- 
ing the lining membrane of the oesophagus between them. 




FROM THE NATURAL CANALS. 339 
Fig. 175. Fig. 176. 




These forceps are in general use in this city, and are prefer- 
able, we think, to all others. (See an interesting paper by 
Dr. Bond, in the North American Med. and Surg. Journal, 
vol. vi., in which he describes both the forceps and the hook.) 
Sometimes, though happily very rarely, it is impossible 
either to draw the body upwards, or to force it into the sto- 



340 REMOVAL OF FOREIGN BODIES 

mach ; then, if the symptoms be urgent, it remains only to 
make an incision upon it at the side of the neck, and remove 
it from without. 

If the foreign substance be withdrawn from the gullet, it 
is advisable always that the patient should make use of some 
mucilaginous article, as slippery-elm bark, or gum arabic, to 
lubricate the lining membrane and to protect it, while so re- 
cently irritated, from farther annoyance during the passage 
of alimentary substances. And if the offending object have 
been pressed down into the stomach, especially if it be irrita- 
ting, unless it be chemically so, rather than give purgative 
medicines to promote its evacuation per anum, demulcients 
and mucilages should be taken freely by the patient, in the 
hope that it may become more or less ensheathed, and thus 
be rendered harmless : if it be likely to do mischief by chemi- 
cal action, the proper antidote should be promptly and suf- 
ficiently administered. 

5. Extraction of foreign bodies from the Larynx and 
Trachea. — During the act of inspiration, the glottis is opened 
widely for the ingress of air, w^hile but a narrow chink re- 
mains during expiration. Hence, during a fit of crying, 
laughing, coughing, yawning, or the like, the unusual inward 
rush of air often suffices to suck in, so to speak, bodies of 
considerable size. Among the articles which have been thus 
drawn into the trachea, are pieces of money, (a half sovereign, 
for example,) cherry and plum stones, small pebbles, grains 
of coffee and corn, teeth, (in one instance, a large molar with 
its fangs,) pieces of grass, fragments of bone. The object 
once in, escape is difficult, from the diminished size of the 
orifice, but especially from the spasmodic closure of the glottis, 
which the presence of an irritant almost necessarily induces. 

The symptoms produced by this accident vary according 
to the position occupied by the intruder. If it be fixed in 
the rima glottidis, asphyxia is rapidly produced, and speedy 
loss of consciousness and death, unless relief is procured by 
surgical interference. If it be moveable in the larynx and 
trachea, and if it change its position from time to time, these 
alterations of site may occasion violent spasmodic cough, con- 
tinuing until complete exhaustion is produced, when a tem- 
porary cessation occurs, to be followed, upon revival, by the 
same phenomena. In other cases, the cough is only occa- 



FROM THE NATURAL CANALS. 341 

sional and much less violent, resembling more the paroxysms 
of hooping-cough ; again, it is more like that which attends 
an ordinary catarrh, or a pneumonia, so as to be mistaken for 
one of these ; the nature of the expectoration is also similar 
to that of these affections. Auscultation will aid the recog- 
nition both of the cause of these aberrations, if the history 
have been unknown, and of the portion of the body, es- 
pecially if it be impacted anywhere, because such a condition 
almost always occasions local pneumonia, or collapse of that 
portion of the pulmonary structure which is connected with 
the bronchial tube thus occluded. Frequently, too, the exist- 
ence of the foreign body in the trachea and larynx, may be 
recognised by feeling it with the fingers placed on the outside 
of the passage, and its motions up and down in the tube may 
thus be followed. Besides the local symptoms enumerated, 
the general condition of the patient suffers, he becomes ema- 
ciated, feverish, kc. ; in fact, many persons who have acci- 
dentally had a foreign body lodged in the trachea, have been 
supposed to labour under tuberculous diseases of the lungs. 

The cause of all these troubles may remain entangled in 
the ventricles and folds of the larynx, or be impacted in its 
general cavity, or in that of the trachea ; it may have passed 
into one of the bronchia, the right most probably, because of 
the size and direction of the latter ; it may even slip farther 
down into one of the smaller subdivisions of the bronchial 
tubes ; or it may, as we before hinted, be arrested at the chink 
of the glottis, either at its first descent, or subsequently 
during expiration. 

Before resorting to mechanical interference, the surgeon 
should satisfy himself by careful investigation into the history, 
as well as the present phenomena, of the case, that a foreign 
body has passed into the respiratory canal, and that the symp- 
toms are not due to inflammation, nor to impaction in the 
oesophagus or pharynx. 

Clearly, the attempt at removal of the object in question, 
by forceps passed into the larynx and trachea, is out of the 
question. The surgeon must decide between performing tra- 
cheotomy and laryngotomy ; and removing the body through 
the wound, on the one hand, and trusting to the expulsive 
efforts of the patient, aided by the surgeon. The first of 
29* 



342 REMOVAL OF FOREIGN BODIES 

these proceedings does not concern us in this treatise ; we 
refer our readers to works on practical surgery. 

As regards the second course, it is very encouraging to find 
that Nature does often accomplish the extrication of the 
patient from circumstances of great peril ; but the surgeon 
should be prepared to step in at any moment and perform 
the operation, if suffocation be imminent, or if there seem to 
be a probability that the longer sojourn of the foreign body 
in its abnormal situation will cause the death of the patient 
by the irritation, inflammation and exhaustion, which it 
occasions. 

If violent spasmodic cough be induced at any time, with- 
out tending to cause the extrusion of the foreign body, but 
serving only to wear out the patient's strength, it may be well 
to try the effect of anaesthetic inhalation, to diminish the sen- 
sibility of the air-passages, unless the substance be supposed 
to be impacted at the glottis ; and even then, the inhalation 
might have the effect of extricating it from its present position 
by relaxing the muscular spasm. Again, if a violent fit of 
coughing be induced, the patient should be inverted, and at 
the same time struck smartly between his shoulders ; by these 
simple means the air-passages have been relieved of their 
troublesome occupant. 

In the well known case of Mr. Brunei, the engineer of the 
Thames tunnel, an apparatus was constructed, with a hinge 
in its centre, upon which he was extended ; so that one end 
being elevated, the other was depressed, and thus the patient 
was inverted with as little suffering and fatigue to himself as 
possible. Tracheotomy was performed by Sir B. Brodie, but 
all efforts to remove the foreign body (a half sovereign), by 
forceps introduced through the wound, were unsuccessful; 
the wound, however, was kept open, and on the 16th day after 
the operation, the patient being extended upon his platform, 
by dint of striking his back sharply, the coin quitted the 
trachea and fell into the mouth. 

In conclusion, we may say with Mr. Fergusson, that such 
examples as this, of which there are several on record, 
" clearly indicate the propriety of trying the effect of change 
of attitude in such cases ; for when we reflect how often per- 
sons have died in consequence of the pressure of foreign 
bodies in the air-passages, and how, too, occasionally such 



FROM THE NATURAL CANALS. 343 

bodies have been spit up after months or years of almost con- 
tinued coughing and suffering, it is not unreasonable to sup- 
pose that such a change of attitude, and some such additional 
measures as were resorted to by the gentlemen who conducted 
the treatment of the instances above referred to, might have 
saved many lives." 

For farther details on this important subject, we refer to 
Dr. Stokes's book on Diseases of the Chest ; to an interest- 
ing paper by Dr. Davis, in the New York "American 
Monthly," August, 1854; to Brodie's case, London Medical 
Gazette, July, 1843 ; and to Mr. Porter's treatise on the 
Larynx and Trachea. 

6. Removal of foreign bodies from the Urethra. — 
The urethra of both sexes is liable to be blocked up, more or 
less effectually, by the lodgement therein of fragments of 
calculi, portions of catheters or bougies which have been 
broken during operations, or by foreign substances introduced 
from malicious or otherwise improper motives. The seat of 
the obstruction varies — it may exist at any point. The symp- 
toms are, more or less complete retention of urine, local in- 
flammation and pain. The precise point of obstruction can be 
ascertained sometimes by manipulation of the exterior of the 
canal ; more certainly by the introduction of a catheter or 
bougie. 

To remove the foreig§ body, it will be necessary sometimes 
to resort to many expedients. The simplest is to introduce 
the largest sized bougie or catheter down to the substance, 
hoping that by this great dilatation of the canal in advance 
of the latter, it may be disengaged and forced out by the 
pressure of the urine from behind ; or the ingenious little in- 
strument of Leroy d'Etiolles, should be passed behind the 
impediment, then its arm thrown down, and both withdrawn ; 
or, again, a long slender urethral forceps, such as is shown in 
fig. 177, may be passed up to the obstacle, and efforts made 
to grasp the latter with it, and if necessary the body may be 

Fig. 177. 



344 



REMOVAL OF FOREIGN BODIES 



drilled or crushed at the same time. If the impediment be 
located near the orifice of the urethra, it may perhaps be 
seized with a pair of delicate dressing-forceps, or a loop of 
wire, or be drawn out by means of a bent probe ; or the 
canal may be dilated by the aid of Arnott's fluid dilator, or 
Weiss' metallic dilator. (Fig. 178.) 

Fig. 178. 




If none of these experiments be # successful, nothing re- 
mains save to cut down upon the foreign body and extract it 
through the wound. This proceeding, however, will rarely 
be necessary in the case of the female urethra, foreign bodies 
being extricated from it with comparative facility, owing to 
its straightness, shortness and capacity for dilatation. 

7. Removal of foreign bodies from the Vagina, can 
generally be accomplished without difficulty, if patience and 
gentleness be used, together with a sufficiency of olive oil. 
The passage is susceptible of very considerable dilatation, 
and consequently it can rarely be necessary to divide its walls 
with a cutting instrument ; the forceps and lever employed in 
obstetric operations, may also be resorted to advantageously 
in the case in consideration. 

8. Removal of foreign bodies from the Rectum. — 
Indigestible substances occasionally pass down from the upper 
part of the alimentary canal, and become arrested in the 



FROM THE NATURAL CANALS. 345 

rectum ; or from morbid sensibility of the mucous membrane, 
and a resulting spasmodic stricture of the orifice of the gut, 
feces accumulate in large masses, so as not only to exercise 
a prejudicial influence upon digestion, but likewise to encroach 
upon the other organs contained in the pelvis ; or, finally, 
bodies, various in kind and size, may be introduced into the 
canal from without. 

To ascertain the nature, dimensions and situation of the 
abnormal contents of the rectum, the fore-finger, well oiled, 
should be passed into the bowel, or if this be not sufficiently 
long, a metallic or gum-elastic bougie may be introduced. 

If the intestine be occluded by a mass of hardened fecal 
matter, it may be removed by throwing up an abundance of 
tepid water from a syringe or gum-elastic bag, which will 
soften the accumulation and wash it down little by little ; or 
a scoop, a tea-spoon, or some similar instrument may be care- 
fully employed to break up the concretion. 

If the substance be solid, its removal may be effected by 
means of a pair of lithotomy forceps, or a small lever, such as 
obstetricians make use of. but reduced in size, or the scoop 
employed to clear the bladder of fragments of sand after the 
operation of lithotomy, (fig. 179.) or a loop of wire, intro- 
duced beyond the foreign body and then drawn out. 

Fl<J. 1 



If the object be very large, it may be drilled to fragments 
or crushed, as was done by Dr. Parker, of Canton, in the 
case of the large glass goblet introduced into the rectum of a 
Chinaman, reported by Dr. Ruschenberger in the American 
Medical Journal, April, 1849 ; or the sphincter ani muscle 
may be divided, and thus extraction be facilitated. 



346 TO DIMINISH PAIN DURING OPERATIONS, 



OF THE MEANS OF DIMINISHING PAIN DURING 
OPERATIONS. 

Pain is at all times an inconvenience, and often a positive 
evil both to the surgeon* and to the patient who is undergoing 
an operation, since it interferes with the quiescence which is 
essential to the performance of some operations and of im- 
portance in all ; and, moreover, if it be very violent and pro- 
tracted, it may produce such an impression upon the patient, 
as shall impair the success of the operation, during its per- 
formance and subsequently. Hence the very general custom 
of administering to patients who are about to submit to surgi- 
cal operations " some sweet, oblivious antidote,'' for the pur- 
pose of calming their apprehensions of suffering and danger, 
and to obtund, in a measure, their sensibility to pain, so that 
the operation may be performed with less discomfort to them- 
selves and with more facility to the surgeon, than might 
otherwise be possible. 

With this view, it has been usual to give a dose of one of 
the preparations of opium, a short time previous to the opera- 
tion, so that, when this is being performed, the patient may 
be under the influence of the anodyne, not to such a degree 
as shall completely stupify him, but so far as to be calmed 
and tranquillized by it. The precise amount of opium neces- 
sary to induce this condition, cannot be determined accurately 
and for all cases, since different individuals are susceptible of 
pain and of the influence of narcotics in very different degrees. 
In ordinary cases, from forty to fifty drops of laudanum may 
be administered to an adult, fifteen or twenty minutes before 
the commencement of the operation, and this interval should 
be passed as quietly as possible. 

It has long been known that nitrous oxidje gas and the 
vapours of many vegetable narcotics produce, when inhaled, 
a degree of insensibility to physical suffering, and operations 
have been performed upon persons thus affected; similar 
results have been attained by the influence of animal mag- 
netism. But the importance of these agents is slight, as 
compared with that of more recent discoveries, — the influ- 
ence of inhalations of the vapour of sulphuric ether and of 
chloroform. 



TO DIMINISH PAIN DURING OPERATIONS. 347 

The applicability of the vapour of Sulphuric Ether to the 
purpose now under consideration, was first established by 
Dr. W. T. Gr. Morton, of Boston, on the 30th September, 
18-46. (See Report of the Mass. Gen. Hospital, Jan. 26th, 
1848 — noticed in Am. Journ. of Med. Sc, April, 1848.) 
The influence of Chloroform in producing similar effects, was 
first determined by Professor Simpson, of Edinburgh. (See 
Am. Journal of Pharmacy, Jan., 1848.) 

Since their effects became generally known, these agents 
have been employed to relieve pain in all sorts of operations, 
and in very many diseases ; they have been administered, 
too, by the ignorant as well as by the learned, and without 
any discrimination of cases. It is not at all surprising, there- 
fore, that in many instances injurious, and sometimes fatal, 
consequences have ensued. It would be out of place to dis- 
cuss fully, in this volume, all the circumstances connected 
with the use of these agents. From the post-mortem exami- 
nations which have been had of persons who have died appa- 
rently in consequence of the inhalation of these vapours, it 
would seem that they produce death by asphyxia, — the lungs, 
the heart, the brain, having been found, in these cases, to be 
much congested, and the blood dark-coloured and more fluid 
than usual. The legitimate inference from these facts is, that 
these vapours should not be resorted to in persons suffering 
from congestion of these organs, or in whom any important 
disease of these organs exists. And although it may be 
admitted that a sufficient amount of testimony has been accu- 
mulated to show that the inhalation of these substances is 
not, under proper regulations and in well-discriminated cases, 
attended with material danger, and that it is even a valuable 
aid to the surgeon in many operations, it must also be 
acknowledged, on the other hand, that we have facts sufficient 
to prove that, without these precautions, and where the 
amount of pain to be experienced is not very great, these 
agents should not be used. It should be recollected that the 
mere performance of an operation, with comparative freedom 
from suffering to the patient and with satisfaction to the sur- 
geon, is but one step towards the cure of the affection for 
which the operation is performed : the treatment of the patient 
subsequently is a matter of equal importance ; and with refer- 
ence to this part of the surgeon's duty, any cause which dis- 



348 TO DIMINISH PAIN DURING OPERATIONS. 

turbs the healthy play of important functions, whether it be 
the impression of too intense pain, or of too powerful narcotic 
agents, is to be regarded as an evil. 

The vapour of chloroform is probably less safe than that 
of sulphuric ether, although it acts more promptly and in 
smaller quantity, — six or eight inspirations being sometimes 
sufficient. No precise rule can be laid down as to the quan- 
tity of the fluid, or the period of inhalation, necessary in 
either case to produce insensibility to pain, children and per- 
sons debilitated by disease, or other causes, being affected 
much more speedily than those in opposite circumstances. 
The vapour should be inhaled until the patient becomes insen- 
sible to pain, unless some unpleasant effect be produced before 
this condition is attained ; and this insensibility should be 
prolonged, as may be necessary, by re-application of the 
apparatus to the mouth, from time to time, as the influence 
of previous inhalations passes off. 

Many varieties of inhalers have been contrived for the 
administration of these vapours, some of them complicated 
and expensive ; the object of all, however, is the same, — to 
allow atmospheric air to enter the lungs, loaded with the 
vapour of ether, or of chloroform. This end may be secured 
by using either of the inhalers illustrated by the accompany- 
ing wood-cuts, as perfectly as by the more complex apparatus. 
(Figs. 180 and 181.) " Figure 180 represents a double-necked 



Fig. 180. 



Fig. 181. 




TO DIMINISH PAIN DURING OPERATIONS. 349 

bottle into which the liquid is introduced; through one neck 
of the bottle, a glass tube passes, reaching below the level of 
the liquid ; into the other a bent tube is inserted, through 
which the patient breathes. The tubes must be tightly fixed 
in the necks of the bottle, and the inspirations of the patient 
must be made through the bent tube, his lips firmly compress- 
ing the glass, the air expired from the lungs passing out 
through the nostrils. Figure 181 shows a common wide- 
mouthed bottle, having tightly fixed in the orifice a cork 
through which the tubes enter the bottle as in the other case. 
But it is not necessary to use any apparatus, — a sponge, or a 
piece of linen, wet with the liquid and applied to the mouth, 
being fully as efiicacious and more safe, inasmuch as a suffi- 
cient supply of atmospheric air is more certainly secured. 
The purest preparations only of ether and chloroform should 
be employed. Before commencing the inhalation of the 
vapour, the patient should be placed in the position most 
convenient for the performance of the operation, whatever it 
may be. 

If any individual to whom these agents have been adminis- 
tered should not revive spontaneously, stimulating applica- 
tions should be made to the surface, among the best of which 
is boiling water ; this should be placed in a cup covered with 
a towel, and then the cup inverted upon the chest. (Amer. 
Jour. Med. Sc, p. 556, April, 1848.) Artificial inspiration 
should be resorted to, if other means fail. 

The reader will find details as to the mode of preparing 
ether and chloroform in the Am. Journ. of Pharmacy, for 
Oct., 1847, and January and April, 1848. Numerous articles 
relating to their employment are contained in the Am. Journ. 
of Med. Sc. for 1847-8, to which reference should be made 
by those who may be disposed to test the action of these 
agents. Besides these publications, the author would recom- 
mend attention to the report of Dr. Isaac Parrish, of this 
city, to the College of Physicians, published in the " Transac- 
tions" of that body; to the essays of Dr. Warren, Dr. Simp- 
son, and Mr. Miller ; that of the latter being appended to the 
last edition of his Principles of Surgery. 

30 



APPENDIX OF FORMULA. 



The following list of formulae will be found to contain 
many which have been proved to be valuable in answering 
the indications for which they are directed. 



LOTIONS. 

I. ASTRINGENT LOTIONS. 

1. Wash for secondary venereal ulcers, particularly of the throat — 

R. Cupri sulphatis, 9ij, 
Pulv. cinchonae, §ss, 
Aquae fluvialis, f^viij. 
M. ft. lot.— Dr. Physick. 

2. R. Tinct. myrrhae, fjj — f§ss, 
Aquae fluvial., f^viij. 
M. ft. lot. 



3. R. Creasotae, gtts. xx — gtts. 1, 

Aquae fluvial., f^vj. 
M. ft. lot. 

4. R. Tannin 9j, 

Spt. vini gallici., f§ss, 
Mist. Camphorae, fgvss. 
M. ft. lot. — For salivation, spongy gums, &c. 

5. R. Sodii chlorid., (sol.) 

Tinct. myrrhae, aa f^ss, 
Aquae fluvial., fgiv. 
M. ft. lot. — Uses the same as the last. 

(350) 



APPENDIX. 351 



II. STIMULATING LOTIONS. 

6. R. Acidi nitrici, f3J — f3ij> 

Aquas fluvial., f 3 viij, 
Aquas rosae, f§j. 
M. ft. lot. 

7. R. Ammoniae muriat., 3j — Jij ; 

Aquae fluvial., f 3 viij, 
Tinct. opii, f3J. 
M. ft. lot. — For painful indolent ulcers. 

8. R. Acid, cyanhydrici, fjj? 

Mucilag. acacias, f 3 viij, 
M. ft. lot. — To relieve the itching in prurigo. 

9. R. Hydrarg. chlorid. mit., 3ij, 

Liquoris calcis, g viij . 
M. ft. lot. — " The black wash." 

10. R. Hydrarg. bi-chlorid., grs. x — 9j, 

Liquoris calcis, g viij . 
M. ft. lot. 

11. R. Spt. vini rectificati, 

Tinct. camphoras, aa f^iijss, 

Liquor, plumbi, fgj. 
M. ft. lot. — To be rubbed upon the part several times daily, oc- 
casionally suspending it. For indolent fibrous tumours of the 
breast. — Brodie. 

12. R. Iodini9j, 

Potassii iodid., 3ss, 
Aquae fluvial, f § viij 
M. ft. lot. — For application to scrofulous and other indolent 
tumours. 



III. EVAPORATING AND REFRIGERANT LOTIONS. 

13. R. Ammoniae mur., Jj, 
Potassae nitrat., 3ij; 



352 APPENDIX. 

Vinegar, fgj, 
Aquae fluvial., fgx. 
M. ft. lot. — Schmucker's frigorific mixture. 

14. R. Athens sulphuric. 

Alcohol, 

Aquae plumbi, aa f^j. 
M. ft. lot. 

15. R. Sodii chloridi, 

Potassae nitratis, 
Ammoniae muriat, aa 3ij> 
Aquae fluvial., q. s. ad mist, solvend. 
M. ft. lot.— Druitt. 

16. R. Spt. viiii rectif., f g j, 

Aquae fluvial., f^vij. 
M. ft. lot. 



CERATES. 

17. R. Resinae, gj, 

Cer. flav., §ij, 
Adipis, §v. 
M. ft. cerat. — For burns. — Physick. 

18. R. Cerat. plumbi, s'acet., 

Cerat. simplicis, aa gss, 
Hydrarg. chlor. mit., 
Pulv. opii, aa 3J» 
M. ft. cerat. — For burns, painful ulcers, &c. 

19. R. Unguent, hydrarg. nit., 3j, 

Cerat. simplicis, 3 n j — ^ss. 
M. ft. cerat. — For sore nipples, &c. 

20. R. Pulv. camphorae, 9j — 3j, 

Cerat. simpl., §j. 
M. ft. cerat. — A stimulating salve. 

21. R. Hydrarg. chlorid. mit., grs. vj, 

Pulv. opii, grs. x, 
Cerat. simpl., 3ij. 
M. ft. cerat. — For indurated chancres. 



APPENDIX, 353 

22. R. Acid, hydrocyanic, gtts. xx, 

Cerat. sirnpl., gij. 
M. ft. cerat. — For papular eruptions attended with itching. 

23. R. Creosotae, gtts. xx, 

Cerat. simpl., gij, 
Zinci oxid., jj. 
M. ft. cerat. — For scaly eruptions. 



OINTMENTS. 

24. R. Potassae carb., gss, 

Aquae rosae, fgj, 
Hydrarg. sulph. rubr., gjj 
01. bergam., f^ss, 
Fl. sulphuris, 
Adipis, aa §ix. 
M. ft. unguent. — Batenian's aromatic sulphur ointment, for 
itch, &c. 

25. R. Picis liquid, f|j, 

Salt butter, gij, 
Melt together, and add of 
Common potashes, 3j, 
Grafe's itch ointment. 

26. R. Unguent, hydrarg. fort., §j, 

Antimon. et potass, tart., 3j, 
Iodini, grs. x — xv. 
M. ft. unguent. — To be rubbed upon the part daily, until it pus- 
tulates. For chronic glandular tumours, old indurated buboes, &c. — 
H. Johnson. 

27. R. Morphise acetat. grs., vj, 

Pulv. gallae, 3j, 
Unguent, stramonii, gj. 
M. ft. unguent. — For haemorrhoids. — Harlan. 

28. R. Sodae bi-carb., 3j, 

Adipis, gj, 
Pulv. opii, 9j. 
M. ft. unguent. — For lichen, prurigo, &c. 
30* 



354 APPENDIX. 



LINIMENTS. 

29. R. 01. tiglii., fjss, 

01. cinnamomi, f3J, 
01. olivae, fgj, 
Lin. cantharid, f§ij. 
M. ft. liniment. — ^for neuralgia. — JPro£ Jackson. 

30. R. 01. olivaa, 

Alcohol aa, fgj, 
Tr. camphorae, fgss, 
Aquae ammonias, f^j. 
M. ft. liniment. — For indurated breasts. 

31. R. 01. terebinth, 

01. lini aa Oss, 
01. succini, 
01. juniperi aa f^iv, 
Petrol. Barbadensis, § iij, 
Petrol. American, gj> 
M.— "The British Oil." To be used diluted with olive oil, or 
lard, as a stimulating liniment, or ointment. 



INDEX. 



Abdomen, "bandage for, 93. 
Acids, counter irritation by, 273. 

cauterization by, 285. 
Actual cautery, 284. 
Acupuncture, 278. 
Adhesive plasters, 34. 
.Ether 347. 

Air-passages, catheterism of, 326. 
Ammonia, as a counter-irritant, 272. 
Anaesthetics, 342. 
Anchylosis, relief of partial, 233. 
Aneurism-needles, 297. 
Apparatus for treatment of fractures, 108. 

dislocations, 210. 

the immovable, of Dieffenbach, 115. 
Laugier, 114. 
Larrey, 112. 
Seutin, 113. 
Velpeau, 114. 

of dressings, 29. 

of instruments, 26. 
Arteries, cauterization of, 284. 

compression of, 286. 

ligature of, 294. 

plugging of, 293. 

torsion of, 204. 
Arteriotomy, 257. 
Artery, wound of, in bleeding, 255. 



Bandages, and their application, 65, 
Bandages, compound, 72. 



Bandage, the simple, or the roller^ 65. 

winding of the, 66. 

application of the, 66. 

the circular, 67. 

the compressing, 70. 

the crossed, 69. 

the dividing, 70. 

the expelling, 71. 

the invaginated, 72. 

the knotted, 71. 

the laced, 74. 

the recurrent, 70. 

the retaining, 71. 

the spica, 70. 

the spiral, 67. 

the spiral reversed, 68. 

the split, or tailed, 73. 

the sheath, 74. 

the suspensory, 74. 
Bandaging, Mayor's system of, 75. 
Barton's bandage for lower jaw, 123. 

bran-dressing, 206. 

fracture of the radius, 151. 
Baynton's treatment of ulcers, 36. 
Bathing, 57. 

Bauden's dry suture, 308. 
Bell's inclined plane, 166. 
Belloc's instrument for epistaxis, 300. 
Bleeding, operations for general, 241. 
for topical, 258. 

from the ankle, 250. 

from the arm, 242. 

(355) 



356 



INDEX. 



Bleeding, from the external jugular, 251. 

from the hand, 250. 

from the temporal artery, 257. 

accidents attending, 253. 
Blisters, 268. 

Boyer's apparatus for fracture of thigh, 180. 
Bond's splint for fractured radius, 154. 

gullet-forceps, 338. 

gullet-hook, 338. 
Bran-dressing, 206. 
Breast, handages for the, 90, 91. 
Brown's bandage for fracture of clavicle, 131. 



Canquoin's caustic, 275. 
Carpus, bandages for the, 102. 

dislocations of the, 221. 

fractures of, 159. 
Catheterism of the air passages, 326. 

of the eustachian tube, 315. 

of the lachrymal passages, 312. 

of the large intestine, 325. 

of the oesophagus, 316. 

of the urethra of the female, 324. 
of the male, 318. 
Cerates, 47, 352. 
Charpie, 29. 

Chest, bandages for the, 88. 
Chin, bandages for the, 81. 
Chlorides of lime and soda, 62. 
Chloride of zinc, 275. 
Chloroform, 347. 
Clavicle, dislocations of the, 213. 

fractures of the, 128. 
Clinical frame, 119. 
Clove-hitch, 222. 
Collodion, 38. 

Colles' fracture of the radius, 151. 
Compresses, 32. 
Condyles of humerus, fracture of, 142. 

os femoris, fracture of, 186. 
Coronoid process of ulna, fracture of, 155. 
Cotton, 31. 
Croton oil, 271. 
Cupping, 258. 
Cutaneous irritation, 266. 
by rubefacients, 266. 
by suppurative agents, 273. 

by vesicants, 268. 

Demi-gauntlet, 102. 

Desault's apparatus for fracture of olecranon, 
158. 
of patella, 192. 



Desault's apparatus for fractures of the thigh, 

172. 
Disinfecting agents, 62. 
Dislocations of bones of the foot, 231. 

hand, 221. 

lower extremity, 224. 

trunk, 213. 

upper extremity, 215. 

clavicle, 213. 

lower jaw, 212. 

compound, 232. 
Douche, 54. 
Dressing, general rules for, 49. 

apparatus of, 29. 

instruments, 25. 

Eighteen-tailed bandage, 104. 
Electric-moxa, 278. 
Electro-puncture, 279. 
Epididymitis, Fricke's treatment of, 37. 
Eustachian tube, catheterism of, 315. 
Extending band, adhesive strips for, 177. 

gaiter for, 174. 

handkerchief for, 177. 

Face, bandages for, 81. 
Femur, fractures of, 163. 
Fibula, dislocations of, 230. 

fractures of, 204. 
Fingers, bandages for, 102. 

dislocations of, 221. 

fractures of, 160. 
Fore-arm, bandages for, 100. 

dislocations of, 218. 

fractures of, 148. 
Foreign bodies, removal of, 333. 

from eye, 333. 

from nose, 334. 

from ear, 335. 

from pharynx and oesophagus, 336. 

from larynx and trachea, 340. 

from urethra, 343. 

from vagina, 344. 

from rectum, 344. 
Fox's clavicle apparatus, 129. 
Fractures, general considerations on, 108. 

immovable apparatus for, 112. 

hyponarthecia for, 115. 

Jenk's apparatus for, 120. 

of the bones of the face, 121. 
of the foot, 208. 
of the fore-arm, 148. 
of the hand, 159. 



INDEX. 



357 



Fractures of the bones of the head, 121. 

of the leg, 197. 

of the pelvis, 126. 

of the shoulder, 128. 

of the trunk, 124. 

of the vertebral column, 124. 
of the clavicle, 128. 
of the fibula, 204. 
of the humerus, 138. 
of the lower jaw, 121. 
of the os calcis, 208. 
of the os femoris, 163. 
of the patella, 190. 
of the radius, 151. 
of the ribs, 125. 
of the scapula, 133. 
of the sternum, 125. 

of the tibia, 204. 

of the ulna, 155. 
Fracture-bed, 117. 
Fracture-box, 198. 
Fumigations, 61. 

Gaiter, laced, 107. 

for extension in fracture of thigh, 174. 
Gauntlet, 102. 

Gerdy's bandage for fracture of patella, 192. 
Gibson's bandage for fracture of lower jaw, 

122. 
Gibson's modification of Hagedorn's splint, 

183. 
Good's splint, 155. 
Granville's lotions, 272. 
Groin, bandages for the, 94. 
Guillou's novel method of treating fracture 

of clavicle, 132. 
Gun-cotton, a solution of, for adhesive strips, 

304. 

Hand, bandages for, 102. 

dislocations of bones of, 221. 

fractures of bones of, 159. 
Hare-lip, twisted suture for, 307. 
Head, bandages for, 77. 

fractures of bones of, 121. 
Haemorrhage, arrest of, 282. 

by astringents, 282. 

by cauterization, 284. 

by cold applications, 282. 

by the ligature, 294. 

by matico, 283. 

by plugging, 293. 



Haemorrhage, arrest of, by pressure with the 

hand, 286. 
Haemorrhage, arrest of, by torsion, 294. 

by the tourniquet, 288. 

from the nose, 299. 

from the rectum, 301. 
Hip-joint, dislocations of, 224. 
Humerus, dislocations of, 215. 

fractures of, 138. 

Immovable apparatus for fractures, 112. 
Inclined plane for fractures of the thigh, 
166. 

for fractures of the leg, 202. 
Injections, modes of administering, 327. 

of lachrymal duct, 331. 

by the rectum, 327. 

of the urethra, 329. 

of the uterus, 329. 

of the vagina, 329. 
Instruments for the pocket-case, 25. 
Invaginated bandage for the lip, 84. 

for longitudinal wounds, 309. 

for transverse wounds, 310. 
Irrigation, 52. 
Isinglass-plaster, 38. 
Issues, 276. 

Jarvis's Adjustor, 219. 
Jaw, bandages for, 79. 

dislocations of lower, 212. 

fractures of lower, 121. 
Jenks's apparatus, 120. 
Jorg's apparatus for wry-neck, 87. 
Jugular vein, bleeding from, 251. 
Junks, treatment of fractures of the leg with, 

197. 
Junk-bags for fracture of thigh, 174, 

Knee, bandages for the, 105. 
dislocations of the, 230. 
fractures of the, 190. 

Lachrymal duct, injection of, 331. 
Lancets for bleeding, 245. 
Leeches, artificial, 265. 
Leeches, preservation of, 263. 
Leeching, 261. 
Leg, bandages for, 106. 

dislocations of, 229. 

fractures of, 197. 



358 



INDEX. 



Ligature for the arrest of hemorrhage, 294. 
Liniments, 47, 354. 
Lint, preparation and uses of, 29. 
Lotions, 46, 350. 



M. Le Doyen's disinfectant, 63. 
Mayor and Sauter, clinical frame of, 119. 
hyponarthecia for the arm of, 150. 
for the leg of, 206. 
Moxa, preparation and application of the, 
275. 

Neck and axilla, bandages for the, 86, 90, 99. 
Nitrate of silver, 274. 
Nose, bandages for the, 82. 

fracture of the bones of the, 121. 
Nostrils, arrest of bleeding from the, 299. 



Ointments, 47, 353. 

Patella, dislocations of the, 229. 
fractures of the, 190. 

Penis, bandages for the, 98, 324. 

Pennsylvania Hospital, treatment of frac- 
tures of clavicle in the, 130. 

Pennsylvania Hospital, treatment of frac- 
tures of thigh in the, 173. 

Pennsylvania Hospital, treatment of frac- 
ture of leg in the, 197. 

Pelvis, bandages for, 94. 
dislocations of, 213. 
fractures of, 126. 

Phlebotomy, 241. 

Physick's splints for fracture of thigh, 173. 

Plasters 38. 

Potassa, 274. 

Poultices, 39. 

Pulleys for reduction of dislocations, 217. 

Purse of Pibrac for the tongue, 84. 



Radius, dislocations of the, 220. 

fractures of the, 151. 
Ribs, dislocations of the, 213. 

fractures of the, 125. 
Roller, the, 65. 



Sailor's knot, 296. 

Scapula, fractures of the, 133. 



Scultetus's bandage, 73. 
Setons, 276. 
Seton-needle, 276. 
Sinapisms, 267. 
Spanish windlass, 290. 
Splints of Amesbury, 169, 184. 

Bache, 179. 

Barton, 152. 

Bond, 154. 

Boyer, 180. 

Desault, 158, 173, 192. 

Dupuytren, 151, 205. 

Fergusson, 201. 

Gibson, 183. 

Good, 155. 

Hagedorn, 183. 

Hays, 155. 

Hutchinson, 201. 

Kimball, 182. 

Liston, 181, 203. 

Lonsdale, 124, 140, 149, 193. 

Mayo, 146. 

Mutter, 233. 

Nelaton, 153. 

Neville, 198. 

Physick, 173. 

Smith, N. R., 171. 
Sponge, preparation and uses of the, 47. 
Sponge-tent, 34. 
Spongio-Piline, 45. 
Sternum, fractures of the, 125. 
Stomach, catheterism of the, 316. 
Suture, the continued, 305. 

the dry, 308. 

the interrupted, 305. 

the quilled, 306. 

the twisted, 307. 



Tarsus, dislocations of the bones of, 231. 

fractures of the bones of, 208. 
Tartar emetic, 273. 
Torsion, 294. 
Tourniquet, 288. 
Tow, 31. 



Urethra, catheterism of the, 318. 
injections of the, 329. 



Vaccination, 280. 



INDEX. 



359 



Vaccine virus, preservation of, 280. 
Vagina, injections by the, 329. 
Vaponrs of ether and chloroform, 346. 
Venesection, 241. 

Veins of the arm, anatomy of the, 242. 
Vertebrae, fractures of the, 124. 

dislocations of the, 213. 
Vesicants, 268. 
Vidal's spring-suture, 309. 



Vienna paste, 274. 

Wounds, means of promoting the closure of, 

303. 
dressing of, 302. 
Water, applications of, to surgical purposes, 

52. 

Appendix of formulae, 350. 



THE END. 



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